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LECTURES 

V 



ON 



INFLAMMATION 



BEING 



THE FIRST COURSE DELIVERED 



%\t Mwje at Desmans af f paMpjjw, 



the be;quest OF DR. mutter. 



v BY 

JOHN H. PACKARD, M.D., 

AUTHOR OP "A MANUAL OF MINOR SURGERY;" TRANSLATOR OF MALGAIGNE'S " TRAITS 
DES FRACTURES;" SECRETARY OF THE COLLEGE OF PHYSICIANS, ETC. ETC. 

■ 4 Ss, 



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«■ PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

1865. 




Entered, according to Act of Congress, in the year 1865, by 

J. B. LIPPINCOTT & CO., 

In the Clerk's Office of the District Court of the United States for the Eastern 
District of Pennsylvania. 



TO 

SAMUEL D. GROSS, M.D., 

PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE. ETC. ETC. 

Dear Doctor: — 

Permit me to dedicate this little volume to you, not 
less in consideration of your distinguished labors in the 
study and teaching of pathology, than in token of thanks 
for the very kind encouragement you gave me in the prep- 
aration and delivery of these lectures. 

Very respectfully yours, 

J. H. P. 



PREFAC E. 



By an agreement entered into in 1858, the late Dr. 
Mutter bequeathed to the College of Physicians of Phila- 
delphia his pathological museum, together with a fund 
for its preservation, and for the endowment of a lecture- 
ship under their direction. The College did me the honor 
to appoint me to deliver the first three courses of lectures 
under this bequest ; and the volume now placed before the 
medical public contains the first series of these lectures. 

In them I have endeavored to set forth the subject of 
Inflammation in the light of modern pathology. As a 
matter of course, within such limits it would be vain to 
attempt to exhaust a topic of such magnitude and import- 
ance ; but my aim has been to take up the principal points 
in regard to it, and to give a plain and succinct exposition 
of their present aspect. How far this end has been at- 

(v) 



VI PREFACE. 

tained, others must judge ; my best efforts have been 
given to the task. 

I feel constrained to thank Drs. A. Hewson, T. G. Mor- 
ton, Edward Rhoads, and Thomas Wistar, of the Penn- 
sylvania Hospital, Drs. C. Morris, and G. H. Humphreys 
of New York, for their kindness in furnishing specimens, 
etc. for the illustration of these lectures in their delivery. 

J. H. P. 

Philadelphia, July, 1865. 



CONTENTS. 



LECTURE I. 

Introductory Remarks — Disease not a Superadded Entity — General Causes of Dis- 
ease — Relation of Inflammation to other Diseases — Inflammation always a 
Disease — Always the same — Always a Modification of the Nutritive Process 
— Normal Nutrition — How altered within the Bounds of Health 9 

LECTURE II. 

Comparison between Organization of the Living Body and that of an Army — 
Phenomena of Inflammation — Diagnosis — Redness; its Main Cause an In- 
creased Flow of Blood to the Part, due not to Relaxation or Activity of the 
Vessels, but to the Vis a Fronte exerted by the Cell-elements — Heat ; Degree 
of; Cause of, chiefly Combustion ; Views of Carpenter, Draper, Dalton, and 
Milne-Edwards on this Subject 39 

LECTURE III. 

Phenomena of Inflammation continued — Swelling; caused mainly by Fulness of . 
Blood-vessels ; also by Enlargement of Tissue-elements, and by Deposit of 
New Material between them — Effusions — Pain; Subjective and Objective — 
Alteration of Function — Connection between Nutrition and Function — All 
these Phenomena are coexistent, but are unequal in Proportion — Chronic 
Inflammation — Erysipelas — Influence of Inflammation on the General Blood- 
mass — Constitutional Symptoms of Inflammation, or Symptomatic Fever 71 

LECTURE IV. 

Causes of Inflammation — They must operate on Individual Cells — They may be 
Mechanical, Chemical or Vital — Irritability — Reflex Nervous Influences — 
Direct Response of Cells to Stimulation — Mechanical Causes — Chemical — 
Vital — Rationale — Law of Irritability, Functional, Nutritive and Formative 
— Law of Reaction — Law of Mutual Relation of Parts — Law of Sympathy — 
Special Applications of these Laws — Tendency to adhere to Normal Type — 
Contagious Inflammations — Influence of Heat and Cold — Tubercle and Can- 
eer as Causes Inflammation 105 



(vii) 



Vlll CONTENTS. 



LECTURE V. 

Terminations of Inflammation — Only two in Number — Vis Medicatrix Naturae — 
Rationale of Resolution — Gangrene — Difficulty in tracing its Rationale — 
Products of Inflammation — Strictly speaking but two — Lymph and Pus — 
Lymph — Its Source — Circumstances influencing its Character — Theories as 
to the Rationale of its Formation 137 

LECTURE VI. 

Origin of Lymph — Theory of Blastema — Schwann's Views — Virchow's Views — 
Cells always derived from Cells — Development of New Cells by Division of 
Parent-cell — Endogenous Cell-growth — Lymph derived from the Cells of 
Epithelium or of Connective Tissue — Its Purpose not essentially Protective — 
Development of Lymph — Usually into Connective Tissue — Other Forms — How 
influenced — Development of Lymph into Heterologous Elements — Forma- 
tion of New Vessels — Hunter's View — Modern Theories 164 

LECTURE VII. 

Mode of Development of New Vessels in Inflammatory Lymph — Of Lymphatics, 
etc. — Office of Lymph in the Repair of Injuries — Atrophy of Lymph — Pus — 
Physical and Chemical Characters — Microscopical Appearances — Movements 
observed in Pus-corpuscles — Origin of Pus — Views of Different Authors — 
Modern View 1 186 

LECTURE VIII. 

The Study of Pus continued — Its Relations with Lymph — With Connective Tis- 
sue—With Epithelium — Histological Substitution — Relations of Pus with 
other Tissues — Pus has no Solvent Power — Relations of Pus and Mucus — 
Final Destiny of Pus — Its Object not Protective — Pyogenic Membranes, so 
called — Ulceration — Its Rationale — Typical Cases — The Process a Negative 
one 209 

LECTURE IX. 

Granulations — Character of in a Healing Sore — Analogy with Formations of 
Lymph elsewhere — Forster's Description — Analogy between an Ulcer and an 
Abscess — Mode of Healing of an Ulcer — Every Step of the Process due to im- 
mediate Causes — Cicatrization — Modifications of Inflammation by Structure 
of Parts — Parenchymatous Tissues — Mucous and Serous Membranes 232 

LECTURE X. 

The Therapeutics of Inflammation — General Relations of Pathology and Thera- 
peutics — Inflammation always calls for Treatment — Object of this, to restore 
Normal Conditions of Nutrition — Various Ways of attaining this Object — 
Effects of Cold — Of Warmth and Moisture — Of Counter-irritants — Of General 
Bleeding — Of Derivatives — Of Low Diet — Of Anodynes — Of Astringents — Of 
Alteratives — The essential Aim in all these Cases the same — Conclusion 254 



LECTURES ON INFLAMMATION. 



LECTURE I. 

INTRODUCTORY REMARKS DISEASE NOT A SUPERADDED ENTITY — GEN- 
ERAL CAUSES OF DISEASE RELATION OF INFLAMMATION TO OTHER 

DISEASES INFLAMMATION ALWAYS A DISEASE ALWAYS THE SAME 

ALWAYS A MODIFICATION OF THE NUTRITIVE PROCESS — NORMAL 

NUTRITION HOW ALTERED WITHIN THE ROUNDS OF HEALTH. 

It would scarcely be possible for me, gentlemen, 
to enter upon the task with which you have honored 
me, without dwelling briefly upon the circumstances 
of interest which attach to the occasion. 

But one other endowed lectureship of a medical 
character exists, within my knowledge, in the United 
States ; it was founded by Dr. Shattuck, of Boston, 
and is on the important subject of Pathological 
Anatomy. The value of such establishments has 
however been amply proved by their results to sci- 
ence in the old world; and it is to be hoped that as 
our country advances in age and prosperity, these 
and all other means for the encouragement and pro- 
motion of learning may be more and more appreci- 
ated, and bear ever-increasing fruits. 

As most of you are aware, the arrangement under 
which this endowment was effected was one of the 
last matters of business which engaged the attention 

2 (9) 



10 LECTURES ON INFLAMMATION. 

of our late distinguished fellow-member. It was 
perhaps the very last strictly professional act which 
he performed; and fitly closed his brilliant and suc- 
cessful career as a practitioner and professor of sur- 
gery. But it is not my duty now to eulogize Dr. 
Mutter, nor is it indeed necessary. His personal 
character and influence are still fresh in the memory 
of many, if not of most of those now present; and 
his name will long live in the annals of American 
surgery. His efforts and reputation as a teacher did 
much to maintain Philadelphia in her ancient place 
as the centre of medical education on this side of 
the Atlantic; and the lectureship which now goes 
into operation, grafted upon the oldest association of 
American physicians, is added to the other opportu- 
nities which this city has to offer to students of the 
art and science of healing. It is earnestly to be 
hoped, and may reasonably be expected, that the 
work begun under such auspices may be productive 
of important and permanent results. 

Before entering upon the actual duties of my lec- 
tureship, I cannot forbear congratulating the Fel- 
lows of the College of Physicians upon the success- 
ful completion of their arduous share in the agree- 
ment made with Dr. Mutter. Energy and forethought 
in no small degree have been needed to carry on, in 
the disturbed state of affairs for the last four years, 
an enterprise so costly as the erection of this sub- 
stantial building; which, so long as it stands, will be 
a monument of zeal for the interests of the profes- 
sion, and for the promotion of a science whose fol- 
lowers are eminently free from the greed of personal 
advantage. 



INTRODUCTORY REMARKS. 11 

The subject of the present course of lectures will 
be that of Inflammation. It has been so frequently 
and so copiously discussed by many of the most emi- 
nent thinkers and writers on medical science, that I 
cannot but approach it with diffidence. But I be- 
lieve it will be generally conceded that there is as 
yet no satisfactory theory in regard to this form of 
disease, and that much of what has been written 
upon it is vague and inaccurate. And in view of 
the acknowledged importance of this condition in 
its relation to other pathological processes, there 
can be no danger of wasting the time given to its 
study. 

Let me therefore invite your attention to a careful 
review of the available facts in regard to this morbid 
state. Many of these facts are so simple and fa- 
miliar as scarcely to need mention, except in order 
to the inferences they may support; but others of 
them are complex not only in themselves but in 
their mutual relations, and demand earnest and 
thorough scrutiny. If we would avoid falling into 
the same errors which have beset our predecessors, 
the investigation of this mass of facts must be carried 
on, not with the object of establishing any precon- 
ceived theory, but with an unbiased readiness to fol- 
low wherever it may lead us. I make this remark, 
although it may seem a mere truism, because it has 
special reference to the cause of much of the doubt 
and obscurity which have encumbered the subject 
we are now about to approach. 

For two reasons it wall be unnecessary for me to 
go into the discussion at any length of the history of 
opinion on this subject. In the first place, the dif- 



12 LECTURES ON INFLAMMATION. 

ferent views which have from time to time been put 
forth will naturally come up for comment in connec- 
tion with the points upon which they bear; and, in 
the second place, those of them which merit any de- 
gree of prominence are, in a general way, familiar 
to all who have looked into works on pathology. 

As already remarked, the subject of inflammation 
has been frequently and copiously discussed, and 
that by writers of no mean authority; and yet its 
special literature is but scanty. It would, indeed, be 
by no means a tedious or a difficult task to give a list 
of those Avho have contributed original material to 
it. For, although many if not all writers upon gen- 
eral pathology have adopted opinions on this subject, 
and even defended them with warmth, there has 
been too prevalent a tendency to the discussion of 
existing theories, rather than to the more laborious 
study of facts. Some even among those whose 
writings have carried weight, would seem to have 
thought their task was to select from the views al- 
ready advanced those to which they could give in 
their adhesion, and not to work out the problem for 
themselves. 

More intimately connected than any other morbid 
state with the healthy processes of life, inflammation 
has become better understood as the science of phy- 
siology has been developed during the present cen- 
tury. In regard to all forms of disease, but espe- 
cially I think to this, it may be said that phenomena 
which once stood out as anomalies or impenetrable 
enigmas are assuming their true places under defi- 
nite laws. Or, to speak more correctly, the laws 
governing both healthy and morbid processes are 



DEVELOPMENT OF TRUTH. 13 

coming to light. They have been in force ever since 
order was brought out of chaos, but Hie develop- 
ment of them to human perception is yet in prog- 
ress. 

This term development has a peculiar force in its 
application to natural science. Man's province is 
not the building up of a system to which nature shall 
conform, but the humbler one of tracing out step by 
step the plan originally laid down by Creative Wis- 
dom. Reason tells us that such a plan exists. AVe 
establish special or elementary facts, until their con- 
currence suggests a law. Successive laws are thus 
developed or laid bare, until a system, or something 
like it, begins to appear. Possibly the whole won- 
drous framework may at some future day be revealed. 
Possibly, although upon this it would be idle to spec- 
ulate, the entire series may at last blend into one 
grand fundamental principle. 

And here it maybe properly remarked, that what- 
ever of obscurity there may be in the processes of 
nature is due to man's imperfection. There are no 
conflicting facts, no defective links; all is harmony 
and order. Cause and effect, in constant and legiti- 
mate succession, have been, are, and to the end of 
time will be, invariably bound together. Hence 
may be derived the best argument for earnest and 
untiring research. So far as man can go, his indus- 
try must carry him, in following out the clues which 
facts afford. Nothing can be more opposed to all 
that we know of nature, than the idea that there is 
any capricious or inconsequent variation in her op- 
erations. And even when we pass from the material 
world into the domain of psychology, we still find 

2* 



14 LECTURES ON INFLAMMATION. 

inexorable law governing all mental processes. Not 
a single phenomenon comes to pass spontaneously; 
such a thing is as impossible as that a fully devel- 
oped living being should come out of nothing. 

In stud3 T ing inflammation, or in fact any disease, 
the idea is too apt to obtain that something is super- 
added to the normal economy. But every lesion 
which occurs is in its causes, phenomena, and conse- 
quences as directly and completely amenable to the 
general laws of nature and to the special laws of life 
as are the healthy functions of the body. Disease 
is the condition into which,' under abnormal cir- 
cumstances, the living being passes. It must inva- 
riably be due to one or the other, or to both, of two 
causes, — inherent tendencies impressed upon the 
organism at the very moment of its entrance into 
life, or some force acting from without. Besides the 
mere succession of one action upon another, there 
is a prescribed order of things, a programme accord- 
ing to which there shall take place certain changes, 
such as growth, development of organs, degenera- 
tion, decay, and death. To each being, it may safely 
be asserted, there is such a special programme, as 
to each class or order there is a general one. 

Hence a normal ovum, duly fecundated, and placed 
under wholly favorable circumstances, would of ne- 
cessity undergo its regular developmental changes 
into the perfect, mature organism. And, having 
completed its assigned period of vigorous life, such 
a being would pass into a state of natural decay, and 
finally become effete, or in other words die, or re- 
solve itself again into its inorganic elements. 

Now there may be either in the ovum or in the fe- 



CAUSES OF DISEASE. 15 

cundating material, or in both, deficiencies which 
shall make themselves manifest in the course of the 
development of the animal. Thus may occur va- 
rious monstrosities; certain parts, such as the head, 
an arm, a kidney, being absent. The germ may be 
wanting in the rudiments of muscular fibre in por- 
tions of the future frame ; or some of the elements 
of bony structure may be omitted. 

This deficiency may go so far that only a small 
modicum of the new being is ever formed. Cases 
have not unfrequently occurred in which a mass of 
hair and one or two teeth have constituted the only 
developed parts of what should have been a human 
foetus. 

Redundancy of parts or of tissue-elements is apt 
to give rise rather to deformity than to disease, as in 
the case of supernumerary fingers, toes, or mammary 
glands. 

But in the programme before supposed, there may 
be, perhaps, in the case of any individual, a provi- 
sion inserted for the occurrence of a certain morbid 
condition at a certain time ; so that there is inherent 
in the ovum a tendency to the development, it may 
be at some far remote stage of its life, of cancer, 
syphilis, or tubercle. Some of the cutaneous dis- 
eases, such as eczema, may also be thus inherited. 
With the nature and mode of this transmission we 
have now no concern, interesting as are the topics 
suggested by its mention. 

The only other way in which disease can originate 
in the economy is by the influence of external causes. 
Mechanical, chemical, electrical, or other conditions 
definable by physics may thus disturb the organism 



16 LECTURES ON INFLAMMATION. 

or some one or more of its parts. And there is still 
another set of agencies for which the best term with- 
in my knowledge is " vital." They can only affect 
living beings, and seem to deal altogether with the 
special manifestation of force constituting life. 

Apparent exceptions to this statement may be 
found, as for example in malignant growths, and in 
contagious diseases. Here it would seem as if there 
were actually an engrafting upon the system of para- 
sitic beings. But in the former case it may easily 
be shown that the new formations are but the out- 
croppings of tendencies inherent in the germ. They 
are not foreign bodies, but as it were organs, in 
which the very same law r s of life are in full force, as 
in the production and maintenance of any other 
organized tissue. In the latter case, it is the subtle 
influence by which the disease is communicated 
which lies beyond human ken. J3o far as the phe- 
nomena go, small-pox is as easily understood as car- 
buncle. In both cases the mode in which a particu- 
lar morbid action is set up at a particular spot is for 
us a mystery. 

The superaddition of something to the normal 
economy, or to any part of it, may induce inflam- 
mation, as in the well-known instance of poisoning 
by certain plants, but here in fact the organism, or 
a part of it, merely responds to a certain stimulus, 
by changing its state. 

Now it is, perhaps, scarcely necessary to go into 
an argument to show that inflammation cannot be 
inherent in a germ; that it cannot be due either to 
deficiencies or redundancies in parts, except as a 
secondary consequence; or arise as the result of a 



POSITION OF INFLAMMATION. 17 

tendency in the new being, as syphilis, cancer, or 
tubercle so often do. It must be excited directly 
by the influence of some agency outside of the part 
affected. It is the response to an applied stimulus 
or irritation. 

Being so excited, inflammation may constitute the 
sum and substance of the abnormal process. Or it 
may be that the cause of it, such as the poisoning of 
the system by small-pox, or of the urethra by gon- 
orrhoea! contagion, is the main disease, to which the 
minor and secondary state of inflammation is more 
or less exactly proportioned in its extent and sever- 
ity. * Or, again, an inflammatory state may itself give 
rise to disorders which present special symptoms and 
entail special disturbances ; of this we have examples 
in cirrhosis of the liver, or in gangrene of a limb 
from arteritis. 

Hence it may be said that the relation of inflam- 
mation to other diseases is very analogous to that 
which, in grammar, the verb "to be" bears to other 
verbs. It is sometimes met with by itself; some- 
times as the principal condition, to which others 
are auxiliary; and sometimes, perhaps oftenest, as 
itself the minor and subordinate element of the 
chain. 

Few, if any, of those groups or successions of 
symptoms to which we give the name of diseases are 
wholly unconnected with inflammation, either as an 
essential or even prominent and constant lesion, or 
as an almost inevitable consequence. And here we 
touch a very difficult topic, so far as strictly medical 
disorders are concerned; most surgical affections are 
in this respect of readier explanation. For instance, 



18 LECTURES ON INFLAMMATION. 

the rationale of the bronchitis and the inflammation 
of Peyer's patches, so constantly met with in typhoid 
or enteric fever, has never yet been cleared up; that 
of the inflamed state of the tissues in the neighbor- 
hood of a cancerous tumor, or a broken bone, is com- 
paratively easy to be understood. In other words, 
the cause and its effect are in surgical diseases apt 
to be in closer apposition. How far an actual analy- 
sis of the process can be carried, remains to be seen; 
I shall attempt such an analysis presently. 

There is no difficulty in conceiving of grave dis- 
ease, such as cancer or tubercle, running its whole 
course, even to the destruction of life, without any 
high degree at least of inflammation being set up. 
Why this is not apt tp be the case will appear as we 
proceed. But it very often happens that secondary 
malignant disease takes place, as in the lymphatic 
glands of the axilla in mammary cancer, without 
inflammation from first to last; showing clearly 
that the latter state is not inseparable from the 
former. 

But there are some diseases, such as small-pox, or 
vaccinia, in which inflammation is an inseparable 
constituent. It arises from the localization of a gen- 
eral poison, and passes off when this poison ceases 
to act as an irritant. I say as an irritant, for every 
one knows the permanence of the subtle effect of 
the diseases mentioned upon the system. The mere 
admission of this statement is enough for my present 
purpose. 

As to the modes in which inflammation is brought 
about, I shall have occasion to speak more appropri- 
ately hereafter, when the subject of its relation to 
other diseases will also again come up. 



INFLAMMATION A DISEASE. 19 

This expression "other diseases" implies that in- 
flammation is itself a morbid state. Now there are 
conditions of the body, or of parts of it, which are 
according to circumstances healthy or otherwise; 
and the expressions often used by medical writers 
would denote that it might be so with the one we 
are now considering. But I take the position that 
inflammation is always, wherever met with, a dis- 
ease; and that the term "healthy inflammation," 
and all the theoretical views dependent upon it, are 
incorrect. 

I say all the theoretical views, because, as is well 
known, we sometimes in practice seek to bring on a 
certain degree of inflammation in a part. But, in 
so doing, we aim at the incidental benefits which 
experience teaches us will be obtained. In morals 
we are forbidden to "do evil that good may come;" 
but not in physics. The only way known to us of 
inducing the formation of lymph is to excite inflam- 
mation; and we risk this, as in cases of ununited 
fracture, in order to attain the desired bond between 
the broken parts. An inflammation of the skin is 
less dangerous than that of the lung or brain ; and 
we excite the former in pneumonia, or encephalitis, 
just as a man leaps from the window of a burning 
house rather than perish in the flames. Of the two 
evils, we prefer the less to the greater. 

The currency which the term "healthy inflamma- 
tion" has derived from frequent use, in medical 
writings as well as speech, makes it necessary to 
defend the position now taken. 

If we imagine a living being passing through all 
its appointed stages, from birth to death, in absolute 



20 LECTURES ON INFLAMMATION. 

health, the idea of inflammation is altogether ex- 
cluded. It does not, so to speak, enter into the pro- 
gramme at all. Not one of the normal actions of 
the organism either requires it or gives rise to it. 

On the other hand, a part in a state of inflamma- 
tion is manifestly unsound. Even the unprofessional 
observer recognizes the undue redness and heat, the 
swelling, the pain, and the disordered function. 
Science goes further, and proves that in proportion 
to the degree of the morbid action the part is ren- 
dered more unfit for its regular duty, less tenacious 
of life, and less capable of returning to its healthy 
state. 

Since, therefore, inflammation finds no place 
among the processes of health, but its briefest and 
most general description is a catalogue of abnormal 
phenomena, we may assume with confidence that it 
is a disease. And unless there can be such a thing 
as a healthy or wholesome disease, there can be no 
such thing as healthy inflammation. 

Another position which I would take in regard to 
this disease of inflammation, and one which seems 
to me important as simplifying its study, is that it 
is always and everywhere one and the same thing. 
Hunter, the pioneer in this field, treats separately of 
oedematous, erysipelatous, carbunculous, and spha- 
celous inflammations; and again of the adhesive, 
ulcerative, and suppurative. And these terms, 
which have been more or less employed by all who 
have followed him until within a very few years, 
have a certain degree of descriptive value. They 
have, however, found no place in the writings of 
either Paget or Virchow — the two authors who 



INFLAMMATION ALWAYS THE SAME. 21 

must be acknowledged as the representative pathol- 
ogists of our day. Hunter was the exponent of the 
reaction against the spirit of pure theory, w r hieh had 
led his predecessors into so many crudities and mis- 
takes. He set the example of diligent observation 
and forcible description, — perhaps it is not too much 
to say that he gave a new basis to medical science; 
and it was natural that a redundancy of terms should 
be used to indicate groups of phenomena whose mu- 
tual relations were as yet unknown. 

Eecurring then to the statement before made, that 
inflammation is the response of a living tissue to a 
stimulus or irritation applied to it, I would insist 
upon the view that the essential elements of this 
process are in all cases the same ; that the variations 
in proportionate prominence and severity, which 
they present in different cases, depend upon circum- 
stances, — the seat of the disease, the state of the 
system or of the affected part, the character and in- 
tensity of the cause, and some external conditions 
not yet clearly defined. 

I have thought it best thus to put this view in a defi- 
nite and formal shape, although it will again appear 
in the course of the discussion of the phenomena 
and causes of the inflammatory process. (Edema, 
adhesion, suppuration, gangrene, — all these are inci- 
dental to or consequent upon the disease w^hich we 
have to study; they cannot without error be said to 
bear any other relation to it. 

Inflammation is a morbid change in the nutrition 
of the affected tissue or organ. All its phenomena 
are either modifications of those which go to make 
up the process of nutrition, or results of such modi- 

3 



22 LECTURES ON INFLAMMATION. 

fications. This statement has been made by so 
many authors, and will moreover be so constantly 
shown to be correct as we proceed in our inquiries, 
that it needs only to be put forth here in order to 
introduce a brief survey of the conditions of normal 
life. 

To sum up then the preliminary positions taken 
with regard to inflammation. It is always the direct 
and legitimate result of some local cause. It is al- 
ways and without exception a disease. It is always 
essentially the same. It is a morbid change affecting 
the nutrition of the part in which it is seated. 

Upon the simplest view, there are three essential 
elements in the compound idea expressed by the 
word nutrition. There must be a living organism 
to be nourished. There must be the material 
needed for this purpose. There must be some 
means for keeping up the supply of this material. 

In any case, granted these three conditions, the 
process of nutrition will go on. And it will be 
healthy just in proportion to the health of the living 
substance, the appropriateness of the material fur- 
nished, and the adaptation of the means provided 
for its supply in just the due amount. 

Allusion has already been made to the existence 
of a certain programme, according to which the life 
actions of every organism and group of organisms 
are arranged to be carried out. Corresponding to 
this there is a type to w T hich every organism is or- 
dained to conform. From the simplest monad up 
to the most complex animal, the pre-existence in 
every case of a certain scheme may be asserted. 
And as might a priori have been supposed, the plan 



NORMAL NUTRITION. 23 

of each organism and the arrangement of its pro- 
cesses are exactly proportioned in complexity. 

In the human body, with which alone we need 
now concern ourselves, we find therefore a web of 
conditions, which to the uninitiated might seem 
hopelessly tangled. It may, however, be reduced 
to simpler terms without any great difficulty, by 
approaching it in the right way. 

Leaving out of the question for the present, then, 
all other considerations, and looking only to the ex- 
pression of the essentials of nutrition, we see the 
tissues, the circulating blood, and the vascular sys- 
tem as a whole. In the ovum, at its first stage of 
development, the new being lies in contact with its 
food. As it becomes separated from this, the per- 
manent provisions for its supply go into effect. 

The process by which the tissues of the embryo 
drew upon the vitellus, or yolk, for their own nour- 
ishment and for the formation of fresh elements, 
commonly called assimilation, is the same as that by 
which they derive like supplies for a like purpose 
from the blood as it flows by them. 

It must not be forgotten that the blood is as truly 
a living mass as is the tissue ; and between these, at 
once separating and connecting them, are the living 
walls of the vessels. As the new being assumes its 
shape and proportions, its vessels and the contained 
blood are simultaneously developed, and both are in 
exact ratio in quantity and quality to the rest of the 
organism. The first moment of existence of a heart 
and aorta is the first moment of their pulsation, and 
that pulsation propels the tiny blood-mass, itself just 
called into life, through every part of the little crea- 



24 . LECTURES ON INFLAMMATION. 

ture. Tissues and blood begin their interchange on 
an infinitesimal scale, but with all the perfection of 
plan which shall mark the full-grown being. From 
this time forward, provided there exists the needful 
supply of material from without, the marvelous pro- 
cess never ceases until its appointed time of life is 
fulfilled. 

It is the power of keeping up this interchange, of 
undergoing continual waste and as continual repair, 
of retaining form in spite of and at the same time 
by means of the incessant loss of molecules and sub- 
stitution of new ones for those lost, that constitutes 
vital force. No sooner does this mutual relation be- 
tween the blood and any cell cease, than the active 
life of that cell ceases also. No sooner is there a 
change in the relation, outside of certain bounds, 
than the health of the cell is impaired. And the 
same is true of fifty or a thousand cells as of one. If 
in the liver the cells of a certain portion and the 
blood passing through that portion come to assume 
such a relation that their interchange of chemical 
elements cannot take place normally, a state of dis- 
ease is initiated in that part. 

Now I assume that upon the chemical elements 
aggregated together into the shape of a living being, 
at any stage of its existence, a certain power is be- 
stowed. And I use the word " living being'' to de- 
note the cell, the typical form of life. The chemical 
atoms which constitute a cell hold this power in their 
corporate character. It is the power of living, or, to 
use the common phrase, Vital Force. This term 
seems to me to set forth best the exact property 
meant — an inherent capacity to perform the func- 



NUTRITION. 25 

tions which go to make up life. Further explana- 
tion of it seems to me impossible. Ve merely see 
that the power and the form of life are inseparable. 
The form is the visible sign of the power, and van- 
ishes when this becomes extinct. 

It makes no difference whether this vital force be 
regarded as a mere modification of other physical 
forces,-- -of heat, of electricity, of chemical affinity, 
— or as a special endowment from the Creator to 
each separate creature. In this manifestation, it 
stands alone; man can do away with it, but he can- 
not confer it. 

Between the living tissues and the living blood 
there is an incessant interchange, the blood yield- 
ing up its supplies of nutritive material, the tissues 
using it and returning what they do not want. But 
besides this relation between the tissues and the 
blood, the former are endowed with functions, — it 
may be to give mechanical support, to move one 
organ upon another, to secrete, to carry off and eject 
noxious substances, to feel. Every such action, 
however trifling, involves a change in so much of 
the tissue as takes part in it. Obviously, in a per- 
fect organism, the structures composing it will be 
exactly adapted each to its own duty — each will 
have blood enough furnished to keep it not only 
merely alive, but in a state to do the work required 
of it. 

This, however, does not constitute all of nutri- 
tion in the higher animals. Wherever a nervous 
system exists, it has an important influence upon 
the process in question. Beginning apparently on 

3* 



26 LECTURES ON INFLAMMATION. 

an equality with the liver, or any other organ in the 
embryo, it gradually gains in rank with advancing 
life, until it comes to be a sort of governor and 
regulator of all the rest. Abundant evidence ex- 
ists to show the absolute necessity of its aid to the 
maintenance of due nutrition in the other organs. 
Mr. Paget, in his admirable work on Surgical Pa- 
thology, adduces numerous cases showing the im- 
mediate effect exercised by the division or severe 
injury of a nerve upon the nutrition of the parts to 
which it is supplied. But the latest testimony on 
this point is given by Drs. Mitchell, Morehouse, and 
Keen, in their interesting essay on Gunshot Wounds 
of Nerves. These writers say: — 

" One of the most remarkable of the nutritive changes 
induced by nerve injuries, is wasting or atrophy of the mus- 
cles supplied by such nerves. It may exist alone or be 
associated with like conditions of the skin and its append- 
ages. 

"Atrophy of the muscles of an entire member is sure to 
follow complete division of its nerves when there is no sub- 
sequent repair. In this case the muscles waste alike, the 
areolar tissue shrinks, the vessels fade from view, and the 
pulse becomes feeble and small. The rate at which this 
process goes on varies greatly, but it begins very early in 
extreme cases, and continues until nothing is left but bone 
and degenerated areolar structures, covered with skin whose 
altered surface tells of the singular blight which has fallen 
upon the member. 

"So complete a destruction is commonly the work of 
years ; but where, as we have seen in certain nerve wounds, 
the main artery has been also destroyed or interrupted, 
the atrophy which followed was, as may be supposed, un- 
usually rapid." (p. 69.) 

These authors incline to the belief that there are 
nutrient as well as sensory and motor nerve fibres. 



NUTRIENT NERVE-FIBRES. 27 

Their remarks on this head are so important that I 
cannot but quote them : — 

11 Let us now add to these facts, that a nerve may be hurt 
and partial paralysis occur without atrophy, and that the 
atrophies bear no strict relation to the extent of the paraly- 
sis, and we shall have acquired sufficient evidence to show 
that there are in muscles motor nerve-fibres and nutrient 
nerve-fibres, and that the animating centre of these latter lies 
in the spinal column. On this theory, and on this alone, 
can we explain all the facts before us. 

"Analogy also lends us some support; since, as we shall 
hereafter point out, it is necessary to admit that in the skin 
as in the muscles there are nerves of special function and 
nerves presiding over its nutrition. In fact, the proposition 
which we have thus stated is well sustained by the views of 
many modern physiologists, and will but be strengthened by 
these added proofs. 

"When, therefore, a nerve is injured, the muscles may be 
paralyzed, sensation destroyed, or nutrition attacked. But 
for obvious reasons these triple results will usually occur in 
one and the same case, but in differing degrees, — as motor, 
sensory, or nutrient nerve-fibres happen to suffer more or 
less." (p. 75.) 

They further say of these nutrient nerves : — 

"Whether they are sympathetic fibres, as we believe them 
to be, and whether they produce effects directly on the tis- 
sues, or only through their control over the vessels, are points 
which our cases do not aid us to clear up, and for these rea- 
sons we decline to discuss them." (p. 76.) 

It is not my present purpose to enter at any length 
into this subject, but I cannot forbear mentioning 
one or two points in regard to the idea that the nu- 
trient nerve-fibres are appendages rather of the spinal 
cord and great sympathetic than of the brain. 

Nutrition may be carried on to perfection without 
any brain at all, as in the anencephalus monsters 



28 LECTURES ON INFLAMMATION. 

sometimes born at full term. Here the spinal cord 
and the sympathetic system are fully developed, and 
from one or both of them must be derived whatever 
nerve-force the other parts of the foetus have needed 
for the carrying on of their nourishment. It may, 
indeed, be argued that the nervous system is itself, 
in intra-uterine life, nothing more than a growing 
mass, like the liver or lungs, and has not yet acquired 
its functions; but the frequent and forcible motions 
of the child within the womb, as well as the fact 
that all the other organs, except the lungs, do exer- 
cise their functions in some degree before birth, 
would militate strongly against such a view. 

Again, the result of Mr. Paget' s observations has 
been, that in cases where " defective nutrition fol- 
lows injury of the spinal cord, it appears to be di- 
rectly due to the injury of the sensitive, rather than 
the motor, nerve-fibres."* But the same author re- 
marks, after mentioning several cases : — 

"None ef these cases, however, enable us to say whether 
the influence on nutrition is exercised through sensitive 
fibres of the cranio-spinal system, or through sympathetic 
fibres; nor do I think this question can be yet determined. " 

We may therefore adopt it as our creed in regard 
to nutrition, that the healthy tissues, being kept in 
relation with blood containing w T hat they need to 
supply their own w T aste and to carry on their func- 
tions, will, under a certain established but not yet 
understood influence from the nervous system, main- 
tain themselves and play their part in the economy 

* Lectures on Surgical Pathology, p. 55. 



THE CELL DOCTRINE. 29 

by means of what they derive from the blood as it 
passes them. 

And here two points seem to call for further no- 
tice : — 

One is the inseparable connection between nutri- 
tion and function. A well-nourished part never fails 
to perform its function, which indeed is the test and 
evidence of its being so nourished. For, be it borne 
in mind, the conditions laid down as those of healthy 
nutrition had to do with both parties to the compact, 
if we may so speak. Healthy hepatic cells cannot 
help taking from the blood coming to them through 
the portal vein the ingredients of bile, if that blood 
is properly constituted; nor can they help taking 
from the healthy blood in the hepatic artery the ma- 
terials to supply the waste incident to their function, 
provided in each case that the due nervous influence 
is exercised upon them. 

Hence function and nutrition may be said to stand 
in a relation of mutual dependence. 

The other point which I would here urge is, the 
great importance of a thorough realization of the 
cell-doctrine and its bearings, in all physiological 
and pathological inquiries. The bare fact that all 
organized beings are made up of aggregations of 
cells may be admitted, but more than this is needed 
to give it its full value in practical research. And I 
think the merit of having developed the capacities 
of this theory belongs to Yirchow, who must indeed 
be looked upon as the leading pathologist of the 
present time. 

The expression before used, that the cells were in 
relation with the blood flowing past or among them, 



30 LECTURES ON INFLAMMATION. 

is sufficiently accurate for general purposes, but not 
for that now in view. For in every tissue in the 
body, so far from each cell lying directly in contact 
with a vessel, the great majority of the cells lie 
either in close apposition to one another, or embed- 
ded in intercellular substance, the interspaces of 
the vascular meshes being filled up with them, thus 
disposed in cumuli. Thus it maybe that some cells 
have five, some ten, some fifty or more others inter- 
posed between them and the nearest blood-current. 
Nay, some tissues, such as articular cartilage, are 
wholly destitute of vessels. 

Hence the process, by which the nutrient material 
contained in the blood finds its way to all the tissue 
elements which need it, must be further explained — 
and this explanation w T ill be found to have an im- 
portant bearing upon some points to be hereafter dis- 
cussed in the pathology of inflammation. 

The mass of blood, which, by any one contraction 
of the left ventricle is driven into the aorta, and 
thence to the body at large, is divided up as it comes 
successively to the arteries of smaller and smaller 
size, until at length it is distributed among an infi- 
nite number of exceedingly minute arborescent sys- 
tems. Here the arterial or elastic character of its 
containing vessels is lost, and the network of capil- 
lary tubes begins, by which the ultimate relation be- 
tween the blood and the tissues is effected. For the 
sake of completeness it may be added, that this sys- 
tem of capillary vessels resolves itself again on the 
other side, if we may so speak, into the venous sys- 
tem, the minute tubes of which, formed by the junc- 
tion of capillaries, run together, and the larger 



CELL-NUTRITION. 31 

vessels so formed again join to form still larger, until 
the blood, gathered up in this way again after its 
function among the tissue-elements has been accom- 
plished, returns to the heart, to be again sent to the 
lungs for aeration. 

During this process of circulation, as perhaps need 
hardly be said, the various organs abstract from the 
flowing blood that which they need for their nutri- 
tion, and those of them whose business it is take 
also the matters to be secreted for further use in the 
economy, as well as such as are to be excreted or 
carried off altogether. Moreover, various effete sub- 
stances are cast back into the blood by the tissue- 
elements, to be carried to the appointed places for 
their ejection or renewal. It is in the capillary por- 
tion of the vascular system that these changes in 
the blood take place; it is therefore of course in the 
tissues corresponding to this that the complemental 
changes are effected. 

Now the point toward which these statements, fa- 
miliar as they must be to many of those who now 
hear them, should lead, is that the relation thus es- 
tablished is between the blood in the vessels and 
every single cell or tissue-element of the mass to 
which those vessels are distributed. There is no 
vagueness; the cell between which and the nearest 
capillary tube fifty other cells intervene, has its share 
of the nutrient material to get, its effete particles to 
throw oft', its infinitesimal share to perform in the 
work assigned to the organ of which it is a part, as 
well as any one of the other fifty. And this is just 
as true of a sluggish and lowly organized tissue, 
such as that of bone, as it is of an active and 



32 LECTURES ON INFLAMMATION. 

highly developed one, such as that of the brain or 
the liver. 

Unless this fact is realized and borne in mind, the 
cell-theory becomes, for all practical purposes, no- 
thing more than a dead letter. It is the secret of all 
tissue changes. 

It would be very interesting to study here the 
subject of the production of animal heat; which, 
indeed, is closely interwoven with that which has 
now engaged us ; but I shall have occasion to bring 
it up again in a connection still more appropriate, 
when the abnormal heat of inflammation has to be 
investigated. I therefore waive it for the present. 

Of course the character and extent of the inter- 
changes between the blood and the tissue-elements 
will be determined by the strength of the special 
affinities existing between these two factors. So 
long as a cell needs what the blood in its neighbor- 
hood contains, and can attract it with more power 
than that by which it is held; and so long as certain 
chemical substances, effete as regards the tissue-ele- 
ments, are either attracted by the blood, or are ex- 
pelled from the tissue-elements and find a place in 
the blood by sufferance, as it were, the interchange 
must go on. So long as the function of a cell is dis- 
charged, so long it wastes away, and must either 
dwindle and die or be repaired by a fresh access of 
material ; which is equivalent to saying that so long 
as the tissue is active, it continually needs new ma- 
terial in proportion to its activity, that it may fulfil 
the law of life — change of material with retention of 
form. And nature provides for the incessant supply 
of this ever-recurring want, in the arrangement of 



CHANGES IN NUTRITION. 33 

the blood-vessel system in such a close and intimate 
relation with the tissues. If in any way this affinity 
is lessened, increased, destroyed, or altered, in just 
such a mode and degree will the mutual relations 
between the blood and the tissues be affected. 

It is a matter of the commonest observation that 
the different tissues possess very different degrees of 
activity in the processes by which they manifest their 
life. And it is equally certain that in the same tissue 
this degree of activity is different at different times. 
The former fact is readily explained on the ground 
that one tissue is intended to discharge an active 
duty, involving much waste and necessitating much 
repair, or, in other words, a very rapid substitution 
of new molecules for the old, while another tissue 
has assigned to it a function in which there is but 
little waste, and consequently but little atomic 
replacement. 

And the chemical composition, as well as the or- 
ganic form with which each part of the living body 
is endowed, corresponds accurately with the share 
it is to take in the processes of the economy. All 
comes to pass according to the scheme of life and 
the plan for the living organism, with an accuracy 
infinitely beyond that which we admire in the con- 
struction of a locomotive or a palace. 

This prearranged plan does not, however, of 
course, account for those changes in the activity of 
a tissue which occur from time to time, and which, 
although oftentimes great and sudden, are still 
within the bounds of health. Such changes are in- 
variably due to some agency external to the tissue 
in which they occur. For the power of spontane- 

4 



34 LECTURES ON INFLAMMATION. 

ous action does not exist in any molecule, atom, cell, 
tissue, or organ of the body. The property of life 
is held by the material elements of the body in their 
corporate character, (to repeat an expression before 
used,) and confers upon them individually no more 
power of independent action than steam acquires by 
being made the servant of man. The only differ- 
ence between these two cases lies in the fact that the 
servants of the organism are banded together in 
squads, to each of which is given a livery, and each 
of which blindly obeys all influences which affect it. 
This principle of blind obedience to the direct op- 
eration of external forces pervades all the material 
part of created nature; it is only in the domain of 
mind or its analogue instinct that anything like vol- 
untary resistance is to be observed. Hence it is not 
possible for a cell or a congeries of cells to elect that 
they will take up more or less nutrient material; 
that they will perform their function quicker or 
more slowly ; or that they will alter the quality or 
character of the matters separated by them from the 
blood. 

Nor does the regulating power reside either in the 
organs of circulation or in the blood-mass. It is 
true that not only is a certain degree of force and 
rapidity of the heart's action necessary to the due 
nutrition of the body, but a more or less exact ratio 
exists between these two things ; and, moreover, cer- 
tain organs or tissues are more sensitive to changes 
in the amount of nutrient material supplied them in 
a given time than others are. But this does not 
involve any power such as that we are now con- 
sidering. 



CHANGES IN NUTRITION. 35 

And if the heart does not possess such a power, 
it does not surely seem that the arteries can. We 
can no more assume that the hepatic artery, or the 
gastric, can resolve at any time to transmit more or 
less blood, than we can that the femoral or the dorsal 
artery of the foot can do so. 

The same argument applies to the capillary ves- 
sels. They have no function except to allow the 
current of blood to flow along them — no contractile 
power except their elasticity, and no active dilatation. 
Of all the distinguishable parts of the body, these 
are the most entirely passive, as to their own state 
at any time. How, then, can they be imagined to 
govern the changes in condition of other organs? 

It is perhaps but right to mention here that the 
views just expressed are at variance with those of 
most authors, physiological as well as pathological. 
The idea which has found general favor is, that the 
small vessels have a capacity of contraction and 
expansion under stimulation, so as to admit more or 
less blood into the part, and thus influence its prac- 
tical activity. But to imagine this to be the case 
seems to me to be to ascribe to the vessels an inde- 
pendent power, an arrogance of control, as it were, 
not warranted by their anatomical position ; and to 
ignore the special tissue-elements, which are both 
structurally and in function far more important. 

These points will, however, necessarily come up 
again, when they can be discussed to better advant- 
age, in connection with the phenomena of inflam- 
mation ; they need not therefore detain us now. 

The blood-mass itself may be regarded as a pas- 
sive member of the economy. It is endowed with 



36 LECTURES ON INFLAMMATION. 

certain affinities, by virtue of which it attracts to 
itself substances already existing in the tissues 
among which it flows, and in like manner gives up 
to those tissues some of its components, either 
essential or accidental. It may of course, as so often 
in therapeutics, be made the channel by which the 
functions of certain organs are influenced, simply 
by adding to it substances which have chemical 
affinities with the tissue-elements. Still, it is clear 
that the blood-mass cannot itself spontaneously in- 
duce any change in the nutrition either of the whole 
body or of any of its parts. 

Where then is the source of these changes in nu- 
trition to be sought? The answer to this question 
can hardly be given in anything like simple terms. 

In the first place, then, we have various changes 
in the surroundings of the animal organism. — 
Changes in the chemical composition, in the tem- 
perature, in the electrical state of the atmosphere. 
Changes in the nature and quantity of the matters 
introduced into the economy in the way of food and 
drink. Changes in the mechanical relations of parts 
to one another as well as to external things. 

Again, we find changes in the nervous system, 
and in the mind, of which it is the direct exponent. 
How these changes arise cannot always, or perhaps 
often, be explained; how they are made operative 
upon other parts of the economy, we have yet to 
discover. But we know that a certain degree of 
analogy obtains between electrical phenomena and 
those of the nervous system ; and to this we cling in 
all our study of the latter. 

It is, however, by the exercise of function, or per- 



CAUSES OF NUTRITIVE CHANGES. Si 

haps more correctly as the effect of the normal 
stimuli which should induce this, that nutrition un- 
dergoes the most marked changes within the bounds 
of health. For in this manner, always supposing an 
adequate supply of nourishment to be ready to make 
good the waste involved, the action of the part is 
quickened, and by virtue of its excitability the re- 
parative process goes somewhat beyond the exact 
measure of the loss. Should the demand for the 
exercise of function be excessive, the loss will be in 
proportion, and the part will be unable to avail itself 
of the means of repair. The terms I have used in 
making these statements may perhaps be open to 
some technical criticism; but they are accurate 
enough to answer the present purpose. 

"When this stimulation of a part occurs, the first 
noticeable effect is an increase in the amount of 
blood flowing through its vessels. The skin be- 
comes flushed, and feels fuller than before, when its 
action is thus quickened. A muscle which has been 
exercised is harder, larger, and more tense than it 
was before — and experiments have shown that its 
temperature rises. 

Now, there is one condition present in such a case 
which we cannot ignore, and yet of which it is very 
difficult to estimate correctly the prominence in the 
whole process. It is the reflex influence of the 
nerves of the part. When the stimulus is applied, 
there is, as it were, a report made to the central 
portions of the nervous system, and a response made 
to this, through the afferent and efferent nerve-fibres 
respectively. This may be either with or without 
the cognizance of the brain — with or without sensa- 

4* 



38 LECTURES ON INFLAMMATION. 

tion. The difficulty then lies in estimating the pro- 
portion in which the response to the stimulus is due 
simply to the tissue itself, or to the influence of the 
nervous system, thus secondarily derived. 

To sum up then the ideas which I have endeav- 
ored to maintain in regard to healthy nutrition. It 
is a process which takes place between every sepa- 
rate cell and the blood with which it is in relation. 
Healthy cells or tissue elements, a due supply of 
suitable blood to them, and a certain influence of 
the nervous system, are the requisites. Nutrition 
and function go together, and are mutually depend- 
ent. Changes in the nutrition of any cell can only 
be brought about by some influence outside of that 
cell ; and this may act either directly upon the cell, 
or through the nervous system, or in both ways. 



LECTURE II. 

COMPARISON BETWEEN ORGANIZATION OF THE LIVING BODY AND THAT 
OF AN ARMY — PHENOMENA OF INFLAMMATION — DIAGNOSIS — RED- 
NESS; ITS MAIN CAUSE AN INCREASED FLOW OF BLOOD TO THE 
PART, DUE NOT TO RELAXATION OR ACTIVITY OF THE VESSELS, BUT 

TO THE VIS A FRONTE EXERTED BY THE CELL-ELEMENTS HEAT; 

DEGREE OF; CAUSE OF, CHIEFLY COMBUSTION ; VIEWS OF CARPEN- 
TER, DRAPER, DALTON, AND MILNE-EDWARDS ON THIS SUBJECT. 

In my lecture of last week, gentlemen, after 
speaking of the general causes of disease in the 
economy, and their division into the inherent and 
the extrinsic, I laid down certain propositions in 
regard to inflammation, the chief of which were : 
that it was always due to external influences — that 
it was always and everywhere a state of disease — 
that it was always one and the same thing — and 
that it consisted essentially in a change of nutrition. 
From this latter proposition I was led into a discus- 
sion of the normal phenomena of nutrition, and of 
its variations within the bounds of health. My 
great object was to show the importance of the 
cells or tissue-elements in the carrying on of all 
the processes of life, and in the changes to which 
they are subject, — in opposition to the views which 
have at times gained even greater currency than at 
present, and according to which the controlling 
power would lie somewhere in the vascular or in 
the nervous system. This importance of the cells 

(39) 



40 LECTURES ON INFLAMMATION. 

is theoretically admitted perhaps by every one, but 
it has not had that influence in either physiological 
or pathological reasoning to which it seems to me 
to be entitled. 

Before proceeding to the discussion of my main 
subject, I would further illustrate the general pro- 
cess of nutrition, by means of a comparison which I 
trust will not seem a forced or a fanciful one. 

Let me then draw a parallel between the living 
body and an army. In both these organizations, 
individuals are massed together for the accomplish- 
ment of common objects; in one sense they cease 
to act as individuals, while in another they con- 
tinue to do so. They are massed for the purpose 
of nutrition and the performance of function ; they 
keep their separate form and shape in order that 
each may take his due share, no more and no less, 
in the distribution of supplies and the assignment 
of duties. 

The men of an army are massed into companies, 
regiments, brigades, divisions, and corps. They 
are uniformed, armed, and equipped. Every officer 
and man has his prescribed duty, permanent or 
changeable; and upon the efficiency with which 
this is discharged by each one depends that of the 
whole. There may be some original defect in the 
material or in the organization of the army, or of 
any portion of it, which shall wholly or partially 
cripple its operations, or which may break it up 
altogether. 

The general commanding controls, through his 
subordinate officers, every individual man in his 
force. He disposes his cavalry, infantry, and artil- 



PLAN OF THE ORGANISM. 41 

lery so as to carry out the plan of his campaign 
or siege. Under him, the quartermaster's and the 
commissary's departments provide for the supply 
of what is needed for the transportation, quartering, 
and subsistence of the troops. The paymaster's and 
the medical departments are also duly arranged. 

If now any corps, division, regiment, or company 
of this army is captured, cut up, discharged, demo- 
ralized, or in any way rendered useless, or injurious 
to the rest, the fact will influence the remainder to 
an extent and degree corresponding with that of the 
disaster. If the officers are inefficient, or there is a 
want of energy or judgment in the quartermaster's 
or the commissary's department, the trouble arising 
will be more or less serious according to the degree 
of the defect and its nearness to the central point 
of the organization. If any portion of the army is 
overtasked, or composed of bad material, the oper- 
ations of the whole will be interfered with just so 
far as they depend on the share to be taken by the 
troops concerned. Should the necessary supplies 
be out of reach, and the stores on hand exhausted, 
the men must suffer individually, and their effici- 
ency as a mass will be impaired in an equal degree. 

In like manner the nervous system may be said 
to control and take cognizance of the state and 
operations of the living body. The digestive and 
circulatory systems furnish the supplies of nutri- 
ment to the whole. And so long as the original 
constitution is sound, the tissues and organs prop- 
erly developed, the functions normally exacted of 
each part, and a due amount of suitable nourish- 



42 LECTURES ON INFLAMMATION. 

ment distributed, the result is and must be absolute 
health. 

But if an injury is sustained from without, or if 
the nervous system is weak and irritable ; if a tis- 
sue is originally defective, or a part is overworked; 
if the supply of nutritive material is insufficient or 
improper in kind, disturbance will ensue. And 
from any or all of these causes disease may arise, 
affecting the whole or a part of the body according 
to the extent and severity of the primary evil. 

Having drawn this comparison, let us now lay it 
aside, to be referred to from time to time as the 
points come up for the illustration of which it is 
meant to serve ; and let us proceed to examine first 
the phenomena, and then the causes, of inflam- 
mation. 

The phenomena by which inflammation makes 
itself known are, — redness, heat, swelling, pain, 
alteration in function, and in most cases effusion 
of new material. These, more or less modified by 
circumstances to be presently mentioned, are the 
evidences of the disease. Suppuration, when it 
occurs, is invariably the result of inflammation. 
Ulceration is either preceded by inflammation, and 
is caused by it, or is attended by it. And when, in 
examining a body after death, we find adhesions 
between parts naturally unconnected, as for in- 
stance between the costal and pulmonary pleurae, 
we know that these are the traces of inflammation. 

Hence this morbid state not only gives rise to 
certain phenomena during its continuance, but in- 
duces results of a secondary and non-essential 
character, some of which are under favorable cir- 



PHENOMENA OF INFLAMMATION. 43 

cumstances but transient, while others pass into 
permanent conditions. 

Singularly enough, it is only these non-essentials 
which, when existing by themselves, afford unmis- 
takable evidence of inflammation. For although 
inflammation may occur without them, they cannot 
be brought about except as its results. Heat, swell- 
ing, redness, alteration of function, — any one of 
these may be due to causes purely physiological; 
but neither effusion of lymph, ulceration, or sup- 
puration, ever exist without a previous or attendant 
inflammation. Pain is often met with where no 
structural lesion is discoverable. 

Instances illustrative of these statements are not 
far to seek. Heat, swelling, and redness are the 
well-known phenomena of the erethism of erectile 
parts, and of the irritation which, although it often 
borders upon inflammation, and may run into it, is 
a state quite distinct from it. Alterations of func- 
tion, in degree and quality, are frequently observed, 
in the various glands, in the nervous system, in the 
stomach, without any of the symptoms being pres- 
ent which are known to indicate inflammation of 
those parts. And the pain of neuralgia, severe and 
wearing as it often is, neither results from inflam- 
mation nor gives rise to it. 

It is therefore the conjunction of all these symp- 
toms to which the name of inflammation is properly 
applied. 

But there are cases of this disease in which some 
of the phenomena usually belonging to it are either 
absent or masked. Such are those inflammations 
which occur in parts where mechanical obstacles 



44 LECTURES ON INFLAMMATION. 

exist to the swelling — as for instance under strong 
fasciae ; or in parts possessed of but little sensitive- 
ness, and in conditions of the constitution which 
blunt the nervous system to pain, as in the pneu- 
monias of old and imbecile subjects. Alteration in 
function can scarcely fail to ensue upon inflamma- 
tion, but may attract little notice, either because, as 
in the case of the spleen, the normal performance 
of the function is not directly observable, or be- 
cause other parts are apparently more involved, 
as when joints are inflamed, but the difficulty of 
motion seems to lie in the neighboring tissues. 

From what has now been said, it may be justly 
inferred that it is not always easy to discriminate 
between the inflammatory state and those condi- 
tions which present some of its symptoms; and 
the practical results of error in diagnosis in such 
cases have been highly disastrous. I say "have 
been,'' because it is much less common for practi- 
tioners to fail in making this distinction now than 
formerly, before the difference had been clearly 
pointed out; and because moreover, even if the one 
state should be mistaken for the other, the extreme 
measures once in vogue have been in great measure 
discarded, and a less heroic and more philosophical 
practice adopted. 

Nevertheless, in doubtful cases the conditions 
which may mask the phenomena of inflammation 
should not be forgotten; and obscure symptoms 
should be traced carefully up to their real causes. 
Often the constitutional state of the patient serves 
to clear up the matter, irritative fever seldom if 
ever failing to attend inflammations of important 



REDNESS. 45 

organs or of high grade, although their immediate 
indications may be ill-defined. 

I propose now to take up the phenomena of in- 
flammation one by one, with a view to determin- 
ing their causes and their significance. Those phe- 
nomena are, to repeat once more, — redness, heat, 
swelling, pain, effusion of lymph, and alteration of 
function. 

The redness of inflammation varies greatly, as 
every one knows, in different cases; and this not 
only in degree but in form. It is sometimes pink, 
sometimes crimson, scarlet, or purple — sometimes 
diffused evenly over the whole surface of the af- 
fected part, sometimes shading off' gradually from 
a central focus. In true inflammations it always 
passes imperceptibly into the healthy color of the 
neighboring tissue. 

The differences named depend partly upon the 
character and extent of influence of the cause of 
the disorder, partly upon the anatomical struc- 
tures concerned. When the disturbing cause acts 
strongly upon a small area, the redness seems to 
find its focus here, and to diminish in every direc- 
tion around it, as when a small foreign body is 
embedded in the skin. When, as in the case of a 
superficial burn or scald of some extent, a large 
area is involved, the whole of this area may be 
deeply reddened, the toning down into healthy 
color occupying but a narrow margin around its 
border. 

Again, in some tissues the morbid state tends to 
spread around its original seat, as is so often seen 
in the peritoneum and in the conjunctiva. Here, 

5 



46 LECTURES ON INFLAMMATION. 

however, another condition seems to come in; this 
spreading is mnch more apt to occur in parts where 
tactile sensibility is wanting, or very limited in 
degree. 

Inflammations which occur as the result of sys- 
temic disease are perhaps much more apt to attack 
the w^hole of a structure, as for instance in rheu- 
matic sclerotitis, than are those of local origin — 
and hence in the former case the redness is much 
more apt to be evenly diffused. 

But in any case, the cause of the coloring in in- 
flammation must be found in the increase in the 
amount of blood present in the part. And the 
first element in this increase will be the filling up 
of the vessels, as may be seen in the web of the 
frog's foot, irritated while stretched out under the 
microscope. Vessels which in the normal condi- 
tion had flowing through them a free and slender 
stream, will now become distended by a torrent, 
the impetuous rush of which continues until the 
channel becomes choked up by the hurrying crowd 
of corpuscles. 

Another element in the rationale of this redden- 
ing is to be found in the passage of red corpuscles 
through vessels which in the normal state of the 
part were traversed by the liquor sanguinis only. 

Still another, but a less important and less easily 
verified condition, is the breaking down of the red 
corpuscles, and the escape of their coloring matter, 
which becomes soaked up by the surrounding parts, 
so as to stain them. Such a state of disorganiza- 
tion of the blood-mass contained in the vessels of 
an inflamed part could hardly happen, it would 



CAUSES OF REDXESS. 47 

seem, unless the tissues themselves were reacly to 
break clown and lose their vitality. 

Assuming then that the quantity of blood in an 
inflamed part at any given moment is greater than 
it normally should be, it may naturally be asked 
whether this is a mere accumulation, or an actual 
increase in the amount of blood passing through 
the vessels of the part in a given time? And in 
answer to this question, an experiment made by 
Mr. Lawrence, of London, and described by him in 
his "Lectures on Surgery," is often quoted. A 
young man whose hand was inflamed was bled in 
both arms. From the side on which the disease 
was,, Sxv of blood flowed, while §iij were flowing 
from the sound limb. But although this case has 
been again and again quoted by different writers, it 
seems to me that it cannot be received in evidence 
without qualification. Unless the two wounds cor- 
responded precisely in size and situation, — a most 
difficult thing to ensure, — and unless the venous 
system of one arm was exactly like that of the 
other, and the muscles were in the same state of 
contraction in each, the comparison could not be 
made with accuracy. Moreover, the amount of dif- 
ference stated is so great. that it seems in itself to 
cast a doubt upon the correctness of the observation. 

But we do not need to resort to proof of this 
kind. It is manifest that all around the focus of 
the inflammation there is an afflux of blood. An 
incision made into a slightly inflamed part will be 
followed by a copious haemorrhage, often with the 
immediate effect of blanching the surface, and the 
substance of the tissue so far as it can be observed, 



48 LECTURES ON INFLAMMATION. 

so that it resembles much moi^e closely the healthy 
structures around. "When, however, the grade of 
the disease is more severe, the bleeding will con- 
tinue freely for a length of time, only subsiding 
gradually as the excitement is lessened by the direct 
abstraction of the food of the part. The difference 
is one of degree only; more blood obviously flows 
from a slightly inflamed part than from the healthy 
tissue, and the difference is greater in proportion to 
the existing excitement. 

Furthermore, in studying this process experi- 
mentally in the web of the frog's foot, we can 
actually watch the increase in the blood-current. 
We see the thronging corpuscles as they rush along 
the vessels, reminding one of the hasty gathering 
of an excited crowd when a disturbance occurs in 
the streets of a city. 

But this fact of the increased amount of blood 
flowing through an inflamed part is of itself a mere 
step ; the important point is to determine how such 
an augmentation is brought about. And here we 
approach a subject which although much debated, 
still remains unsettled, but which it seems to me 
admits of as complete explanation as any of the 
other phenomena of living beings. That is to say, 
so far as the physical laws and conditions operative 
in these changes are concerned, they can be traced; 
but there is a boundary beyond which we cannot 
go, the Author of life reserving the comprehension 
of that mystery from us. 

The ideas entertained on this subject, even long 
after the corner-stone of our modern system of phys- 
iology was laid in Harvey's great discovery of the 



STATE OF THE BLOOD-VESSELS. 49 

circulation of tlie blood, were singularly vague and 
crude. So eminent a man as Boerhaave described 
the cause of inflammation as twofold: a viscosity 
of the blood causing it to become obstructed in the 
small vessels, and the larger globules of the blood 
passing into channels too small for them. To the 
latter phenomenon he applied the name of error loci. 
Cullen thought a spasm of the extreme arteries was 
the starting-point of all the phenomena of inflam- 
mation; Hastings and "Wilson Philip, on the con- 
trary, argued that the minute vessels became 
debilitated and relaxed, so as to afford less than 
their normal degree of resistance to the blood-cur- 
rent, and thus allow a state of hyperemia to arise. 

Hunter, to whose weight of authority allusion 
has before been made, suggested the idea of an 
active dilatability of the vessels, by which they ex- 
panded so as to admit more blood than in the 
normal state. And this view of " increased action 
of the vessels" has been accepted by many of those 
who have followed him. 

All these theories, however, (some of which 
should rather be called hypotheses,) deal exclusively 
with one only of the factors in the process of nutri- 
tion as we have studied it. It will be remembered 
that the essential elements necessary to a nutritive 
process were, — the structure to be nourished, the 
material needed by it, and a provision for the regu- 
lar and duly apportioned supply of that material as 
wanted. 

Of these three conditions, it is obvious that the 
one last named is subordinate to the other two — 
and in speaking of the process of healthy nutrition 

5* 



50 LECTURES ON INFLAMMATION. 

and its variations, I tried to show that these latter 
could not be ascribed with reason to changes in the 
vascular system merely. There must be a con- 
sensus, — a joint action on the part of the tissues, 
the blood-mass and the vessels, for the regular car- 
rying on of the normal process, and if either one 
of the conditions becomes changed, the others must 
be modified accordingly. 

If at any point an increase in the supply of blood 
is needed or called for, (the tissue-elements being 
stimulated,) more blood will be drawn thither. And 
the current in the vessels of the part becoming fuller 
and stronger, those vessels will give way to the aug- 
mented outward pressure they sustain from their 
contents, and will expand. 

Another argument against the adoption of any 
theory which assigns to the vessels an active part in 
the causing of the increased flow of blood in inflam- 
mation, is that no direct evidence can be derived 
from experiment in favor of such a view. It would 
hardly be worth while for me to quote the descrip- 
tions given by different authors of the phenomena 
observed by them in the transparent parts of some 
of the lower animals, with the aid of the micro- 
scope. It is in the nature of things physically im- 
possible to apply to the vessels alone any stimulus ; 
and hence in the experiments made in the artifi- 
cial induction of inflammation, for the purpose of 
observing its phenomena, the changes which take 
place in the vessels cannot be isolated; they must 
be regarded as only parts of an apparatus. Not 
only the vessels, but also the nerves and the proper 
tissue of a frog's foot must experience irritation 



STATE OF THE BLOOD-VESSELS. 51 

when the point of a needle is drawn across the ex- 
tended web. So also with chemical agents. When 
a drop of acid, or of a solution of salt, is applied to 
the web, we cannot suppose that its influence is un- 
felt by the nerves; nor can we, in view of the con- 
stant endosmotic interchanges that are going on 
between the contents of the capillaries and those 
of the tissue-cells, ignore the fact that such a chem- 
ical agent would be apt to very materially affect the 
relative densities or the affinities of the substances 
concerned. An increase of the endosmotic current 
toward the blood would augment the bulk of that 
liquid, and an enlargement of the calibre of the 
vessels, at the expense of the size of the cells whence 
the flow took place, must ensue. Doubtless this is 
the true explanation of the fact which occasioned 
Dr. Thomson so much surprise, that the application 
of a solution of common salt was followed by dila- 
tation of the vessels. His observation was correct, 
but he erred in his interpretation of it — or rather, 
he wanted the previous facts which would have 
explained it. 

And all analogy is against the supposition of an 
active dilatation of the vessels. Nowhere in the 
body do we see a muscle lengthening itself, any 
more than its owner can add a cubit to his stature. 
Muscular tissue has the property of contracting; 
every muscle has its maximum length, to which it 
attains when all contraction ceases in it, but beyond 
which it cannot go. And in proportion to the 
diminished exercise of contractile force, short of 
actual cessation, the muscle relaxes; but no inge- 
nuity can make this into active dilatation. 



52 LECTURES ON INFLAMMATION. 

The so-called yellow fibrous or elastic tissue 

yields to a stretching force, contracts when this 

ceases, and by mere elasticity may lengthen, just 

as an India-rubber spring will do. Mr. Wharton 

Jones, in a Report on the Theory of Inflammation, 

published in the British and Foreign Medico-Chi- 

rurgical Review, 1844, says : — 

"Animal physiology recognises no other motor agent 
than contractile fibre, i.e. a fibre capable, under certain con- 
ditions, of becoming shortened in the direction of its length, 
and that with force, but when no longer under these condi- 
tions readily resuming its former length." 

Everywhere, to counteract muscle, we have mus- 
cle so arranged as to operate in the opposite direc- 
tion with greater force. The gastrocnemius does 
not actively dilate when the foot is to be flexed on 
the leg, but another set of muscles comes into play, 
and as the former slackens its pull, the latter con- 
tract. The sphincters do not spontaneously elon- 
gate their fibres in order to the enlarging of the 
openings they respectively command, but they yield 
to pressure, and to the more powerful contraction 
of the longitudinal layers of muscle to which they 
are opposed. 

It surely, therefore, is not philosophical to sup- 
pose that capillaries, to all appearance made up of 
wholly structureless membrane, should have a power 
which does not belong to muscle, or to any other 
part of the organism. Nor can we with any more 
reason suppose that either small or large arteries, 
by virtue of an elongating power possessed by their 
circular fibres, can enlarge their calibre. 

A theory which has been suggested to me, but 
which I do not remember to have seen in print, is 



ARTERIAL CONTRACTION. 53 

that the increased flow of blood to an inflamed part 
is caused by the more active contraction of the small 
arteries supplying it, under the influence of the dis- 
turbing agency, whatever it may be, which gives 
rise to the inflammation. But there are several 
arguments against this view, which indeed does not 
seem to materially differ from that advanced by 
Cullen, and before alluded to. In the first place, 
the muscular fibre entering into the walls of the 
arteries is of the unstriped or involuntary kind — 
and the distinguishing feature of this form of tis- 
sue, aside from its appearance, is the slowness of its 
contractions. Like the muscular fibre of the intes- 
tinal walls, it shortens itself gradually; and no 
amount of irritation can induce a rapid alternation 
of contraction and relaxation, such as takes place 
in the heart. The throbbing of the arteries of an 
inflamed part is not due to their own pulsation, but 
to the successive impulses given to a full stream of 
blood contained within them. 

Again, this arterial contraction, if it takes place, 
must be either continuous, or intermitting and pul- 
satile. But if it w r ere the former, it would shut off 
or lessen the stream of blood, instead of increasing 
it; if the latter, it would change the steady flow of 
the current through the capillaries into an oscilla- 
tory one. Xeither of these changes is, however, 
noticed; the flow of blood is augmented in force 
and volume, but does not become pulsatile. 

In further proof of this view may be urged the 
pathological effects noticed as following the use of 
large quantities of spurred rye; which, as I need 
not tell many of those who hear me, contains a sub- 



54 LECTURES ON INFLAMMATION. 

stance which acts upon the involuntary muscular 
fibres so as to cause them to contract. The lessen- 
ing of calibre of the arteries, due to this agent, by 
diminishing the supply of blood, induces gangrene 
of the extremities, not preceded by inflammation 
or congestion. And it would have to be shown, in 
order to uphold the theory that the contraction of 
the arteries is the cause of inflammatory redness, 
that this contraction was different from that due to 
the use of ergot. The idea of its being followed 
by debility and relaxation, and thus by an increased 
flow, is too roundabout to be accepted without more 
exact proof than has yet been adduced. 

Furthermore, if the contraction of the arteries 
going to a part were the cause of its redness, then 
in every instance that redness would correspond in 
extent exactly to the area of distribution of the 
artery concerned ; but it is by no means proven 
that such is the case. We have in an inflammation 
of a small portion of skin, a deeply reddened cen- 
tral spot, from which in every direction the color 
gradually shades away into the hue of the normal 
tissue. It would seem more natural to seek at the 
focus of the disturbance for its prime cause, than 
at one or more points at its margin or outside of it. 

Lastly, the disturbing cause cannot be shown to 
act upon the arteries at all. It may indeed be al- 
leged that it is by a reflex nervous influence com- 
municated to them, but this is a mere supposition, 
not upheld by positive observation. 

I would therefore urge that the fulness of the 
blood-vessels in an inflamed part is due to the in- 
crease which takes place in the attraction of blood 



ATTRACTION OF BLOOD. 55 

to the tissues. Not that the interchange between 
the blood and the tissues is rendered more active, 
(although such may be the case in the early stage of 
the process,) for if this were so, nutrition would be 
promoted; but merely that the irritated part calls 
for more blood, and the call is responded to. If 
the irritation continues, and amounts to inflamma- 
tion, the overstimulated tissues are unable to dis- 
pose of the blood the}' have acquired, which there- 
fore stagnates, blocking up the vessels; and as the 
general circulation goes on, the fresh blood which 
comes to the part must find a passage elsewhere. 
Hence ensues a crowding of the vessels in the 
neighborhood of the focus, and hence the grada- 
tions from the point of greatest obstruction out- 
ward to the healthy parts around. 

"Whether the current be merely rendered slower, 
or checked altogether, it is easy to see why throb- 
bing should take place in the arteries supplied in 
the part affected, and why more blood should flow 
from an opening in the corresponding vein. A 
greater resistance than usual is encountered by the 
arterial wave, which therefore spends its force upon 
the walls confining it, and is more readily percep- 
tible through them. And as the capacity of the 
part to receive blood is lessened, while more, or at 
least as much as usual goes to it, the flow will neces- 
sarily be more forcible wherever the resistance is 
taken away. 

I am glad to be able to adduce, in support of 
these views, the authority of so able a writer as the 
late Dr. Alison, of Edinburgh, who uses the follow- 
ing language: — 



56 LECTUKES ON INFLAMMATION. 

" From all these facts we think ourselves justified in in- 
ferring that inflammation consists essentially in a local 
increase of a vital property of attraction existing among 
the particles of the blood, and between them and the sur- 
rounding textures, and with which other vital properties 
are connected and simultaneously excited. That the prox- 
imate cause of inflammation, although affecting the consti- 
tution of the blood, does not reside in the blood only, but 
primarily in the agency on the blood of the solids through 
which it passes in the capillary vessels, appears clearly from 
the limitation of the disease to a certain locality in the 
body, from the fact of its easy reproduction, for a long time, 
or for life, in the vessels which have once been the seat of 
it, and from other facts to be mentioned as to inflammatory 
effusions."* 

In further illustration of this subject, let me recall 
my military simile. The ordinary distribution of 
supplies by the quartermaster's and commissary's 
department corresponds to that of nutritive mate- 
rial and oxygen to the various parts of the body by 
means of the circulatory system. When from any 
cause, such as hardship or disaster, any portion of 
the army is in need of larger supplies than usual, a 
special requisition is made for what is wanted, which 
is furnished, it may be, by the ordinary channels, 
but in greater quantity than usual. And thus it 
might happen that the roads leading to the spot 
occupied by the troops in question should be 
blocked up by the wagon trains carrying their sup- 
plies. Now according to the view I have advanced, 
it would be just as reasonable to say that this whole 
occurrence was due to an effect produced upon the 
road over which those wagon trains pass, or to the 
increased number of these trains, as to ascribe all 

* Outlines of Pathology and Practice, 1844, p. 84. 



CONGESTION. 57 

the phenomena of inflammation in the frog's web 
to an increased calibre of the vessels or to the aug- 
mented quantity of blood contained in them. 

And the difference between congestion and in- 
flammation may be readily set forth by means of 
the same comparison. If those wagon-trains had 
been sent by mistake or want of judgment to a 
point where they were not needed, or if, in the 
ordinary course of operations, their return to head- 
quarters had been impeded by the rise of a stream 
or the burning of a bridge, the same blocking up 
of the roads would have taken place. And so, if 
blood is in any way furnished to a part in excess 
over the amount needed for its nutrition, the ves- 
sels will be congested and the whole part turgid. 
This may be the case from various circumstances 
which need not be mentioned here. The condition 
produced does, in its visible appearances, more or 
less closely resemble inflammation — but the other 
phenomena are either wanting or far below the 
degree they acquire in the latter state. Such a 
congestion approaches much more nearly to the 
form of disease known as chronic inflammation, 
which will come up for study hereafter. Suffice it 
to . say now, that the state of congestion is more 
transitory, and affects much less deeply the process 
and the power of nutrition in the part. In conges- 
tion the vessels are quite as passive, quite as much 
irresponsible, so to speak, as they were shown to be 
in inflammation ; in fact, I think it may be asserted 
that congestion is one of the elements of inflamma- 
tion, and may exist by itself, just as the pain may 

6 



58 LECTURES ON INFLAMMATION. 

in neuralgia. Neither congestion nor neuralgia 
constitutes inflammation ; but in this latter state we 
have a congestion dependent upon and kept up by 
changes in the nutrition of the part, and a neural- 
gia, a painful condition of the nerves, likewise due 
to certain changes, and rendered persistent just so 
far as those changes are so. Remove the cause of 
the inflammation, and the congestion and neuralgia 
will disappear, as will the other phenomena. 

Perhaps it is scarcely necessary for me to men- 
tion that there are other causes of congestion, which 
are purely mechanical ; and that the state thus 
brought about, as for instance in a foot by the con- 
striction of the leg, or by gravitation, may be prop- 
erly called passive congestion. Such a state of 
things is clearly different from that which has just 
been discussed. 

I would, then, ascribe the redness of inflamma- 
tion to the abnormal fulness of the blood-vessels, 
by reason of the increased attraction of the tissues 
in this state of things for the blood; the conclusion 
by no means following, that the tissues can main- 
tain their ordinary relation to this increased amount 
of blood, since many other facts go to prove that 
what we can best designate as the powers of life 
are diminished instead of being augmented. 

The abnormal flow of blood to the part is due, 
then, not to any vis a tergo, but to the vis a fronte 
exerted by the tissues. Neither the heart, the arte- 
ries, nor the capillaries can of themselves determine 
any changes in the supply to be furnished at any 
time — they can only perform the duty which falls to 
them. They are not more active, and they cannot 



DEGREE OF INCREASE OF HEAT. 59 

be more passive, than they are in the healthy state 
of the whole economy. 

The heat in inflammation may naturally be con- 
sidered next, as being not only, after the redness, 
the most palpable phenomenon of that morbid state, 
but as being closely connected with it in its causa- 
tion. And it was by the combined existence of 
these two conditions, heat and redness, that the 
name inflammation, like the corresponding Greek 
word phlogosis, was suggested. 

That a part which is inflamed has its temperature 
raised above the normal standard for that part, can- 
not for a moment be doubted; but the degree of 
this elevation is generally much less than would be 
supposed either by the patient or by the observer. 
The patient is apt to be misled, because not only 
are the nerves of the affected organ rendered un- 
duly sensitive to heat as well as to the causes of 
pain, but they are the seat of subjective sensations 
resembling those due to extrinsic influences. The 
heat and the pain are both actually felt, but they 
cannot be clearly distinguished the one from the 
other; the patient can scarcely tell how much of his 
discomfort is due to heat and how much to pain, 
but each renders the other more severe. 

On the other hand, the surgeon is liable to over- 
estimate the rise of temperature, partly because his 
imagination is excited by the redness and the other 
phenomena, or perhaps by the very name which he 
gives to the morbid state; and every one knows 
how inaccurate a test of heat sensation is, even in 
the observation of differences. 

Certain it is, that the thermometric changes pro- 



60 LECTURES ON INFLAMMATION. 

duced by this condition are much slighter than 
would be supposed. Hunter held the view that the 
temperature of an inflamed part never exceeded 
that of the central portions of the body; and the 
statement is confirmed by Anclral and Gavarret, 
and by most other writers. 

A greater increase of heat takes place in some 
inflammations than in others. When the grade of 
the disease is high, and the redness very marked, 
when in other words the inflammation is acute, the 
rise of temperature is proportionately great. When 
on the other hand the morbid state has been for 
some time existing, when the changes are going on 
more moderately, as for instance in cases of the re- 
pair of injuries, after the first stage has been passed, 
the heat will be only slightly elevated, if at all, be- 
yond its natural standard. 

It is necessary here to anticipate a statement 
which must be made in connection with the consti- 
tutional symptoms of inflammation, viz., that the 
system at large passes into a febrile condition under 
the influence of this local disturbance. And as one 
element of this disorder, the temperature of the 
whole body rises in some degree. Hence, although 
the part itself may seem to be very much heated, it 
will be found that the central organs are affected in 
like manner and in equal proportion. 

A fact familiar to all who have been in the 
habit of making post-mortem examinations will 
bear somewhat upon this subject. When a body 
is opened soon after death, or when it has been 
kept in a warm room, the air of which is so damp 
as to prevent the body from cooling by evaporation, 



CAUSES OF INCREASE OF HEAT. 61 

the heat felt by the hand of the operator introduced 
into any of the great cavities will be so great as to 
be very disagreeable. Sometimes it may even be 
said to be pungent. And yet this is at least no 
greater than that of the same body during life ; it 
is certainly not above 98° Fahrenheit. 

The heat of an inflamed part is therefore in- 
creased positively, but only to a limited degree ; it 
never passes beyond that of the central organs, and 
varies somewhat with the degree of activity of the 
morbid process. Its mode of production must now 
be inquired into. 

And in the first place we may assert that there 
is no superadded source of heat; wdiatever is the 
origin of the caloric developed in the normal struc- 
ture must also give rise to that which occurs in 
inflammation. Hence we have to go back to the 
study of healthy nutrition, to ascertain what those 
processes are by which the temperature of the living 
tissues is kept up, and which, being increased in 
activity when the change in nutrition begins which 
we call inflammation, induce a correspondingly aug- 
mented development of heat. 

As has been already remarked, no law of nature 
is set aside in the living body, any more than in in- 
organic matter. If a force is overcome, it is by the 
opposition to it of a greater force; if an effect i3 
produced, it is by a direct and legitimate cause. 
Hence in assuming the actuality of a vital force, 
we do not by any means set up a mysterious agent 
by which phenomena are irregularly and sponta- 
neously brought about. It cannot be affirmed that 
the vitality of an organic cell increases by the mil- 

6* 



62 LECTURES ON INFLAMMATION. 

lionth of a degree the amount of heat which would 
be developed or made latent by the same chemical 
changes taking place between the same atoms if 
they were in the state of inorganic matter. 

So far as is now known to science, there are three 
sources of heat: mechanical, chemical, and electri- 
cal changes. According to the views set forth by 
Prof. Tyndall, in his admirable lectures on "Heat 
Considered as a Mode of Motion," it seems prob- 
able that all these may be in strictness regarded 
as identical — the clashing of atoms being the prox- 
imate cause of every development of heat. But for 
our present purpose it will be sufficient to take the 
grosser statement first made. 

As to the mechanical sources of heat in the living 
body, the only one as yet known is the friction of 
the various parts. And although for obvious rea- 
sons the avoidance of friction is one of the ends 
most clearly aimed at in the structure of all organ- 
ized beings, it is probable that there is enough to 
give rise to some degree of heat. This, however, 
cannot be appreciable to any means of testing which 
we possess, nor can it be separated from the chem- 
ical processes which incessantly take place during 
life, and in fact until the atoms composing the body 
have been finally resolved into their original inde- 
pendence. Hence it may be left out of the account. 

The chemical sources of heat may be more readily 
investigated. Chief among these are the combi- 
nations of oxygen with the other elementary sub- 
stances. 

Nutrition, consisting in the taking up from the 
blood by the tissues of the food they want, and of 



CHEMICAL SOURCES OF HEAT. 63 

oxygen; and depuration, consisting in the giving 
up to the blood by the tissues of the effete matters 
they no longer want, are the two great processes 
which begin and end with life. The result of these 
processes is the formation of carbonic acid, water, 
and ammonia. Chemically speaking, they consist 
simply in a series of combustions, incessantly going 
on, and demanding an equally incessant supply of 
fresh fuel. And these combinations are just as 
surely productive of heat as if they went on in a 
furnace, between elements wholly inorganic. 

For, upon the principle before stated that atoms, 
by their association into organic forms, are in no 
way exempted from the ordinary laws of physics, 
but simply acquire a corporate character; the union 
of one equivalent of carbon and two of oxygen 
must, here as elsewhere, give rise to a certain defi- 
nite degree of increase of temperature. As Pro- 
fessor Tyndall would express it, the clashing of 
those atoms would convert their motion into heat. 

To recur to our army illustration, the men who 
are formed into a company or regiment do not lose 
their individuality, but are simply massed for a cer- 
tain purpose. The discharge of one man's musket 
will produce just the same effect as if he were a 
civilian; his aim is no truer, his powder no more 
energetic, than if he had no comrades. It is in the 
moral effect, and in the combined and massed action 
of the whole command, under definite control, that 
the advantage of military organization lies. 

In support of the statement that combustion is 
the source of the heat of the animal body during 
life, it may be well for me to adduce the authority 



64 LECTURES ON INFLAMMATION. 

of standard writers on physiology. Dr. Carpenter 
ascribes the production of animal heat to the burn- 
ing up of fatty and other matters within the body. 
He says: — 

"It may be stated as a general fact, that every change in 
the condition of the organic components of the body, in 
which their elements enter into new combinations with oxy- 
gen, must be a source of the development of heat. And 
as we have seen that a considerable part of the carbonic 
acid and water which are exhaled in respiration, is formed 
within the body by the metamorphosis of its own tissues, 
and that this metamorphosis is promoted by the active ex- 
ercise of the nervo-muscular apparatus, it follows that in 
animals whose habits of life are peculiarly active, while the 
temperature of the surrounding medium is sufficiently high 
to prevent its exerting any considerable cooling influence 
over them, the combustive process thus maintained may be 
adequate for the maintenance of the temperature of the body 
at its normal standard. This seems to be the case with the 
great carnivorous quadrupeds of warm climates, and with 
certain races of men who lead a life of incessant activity 
like theirs. But whenever the cooling influence of the atmos- 
phere is greater, or the retrograde metamorphosis of tissue 
takes place with less activity, some further supply of heat- 
producing material is required ; and this is derived either 
directly from the food, or from a store previously laid up in 
the body. Although the albuminous and gelatinous com- 
ponents of the food may be made, by decomposition within 
the body, to yield saccharine and oleaginous compounds 
which serve as an immediate pabulum to the combustive 
process, yet this metamorphosis involves a great waste of 
valuable nutritive material ; and the needed supply is much 
more advantageously derived at once from those farinaceous 
or oleaginous substances, which are furnished in abundance 
by the vegetable kingdom, the latter also by the animal. 
No reasonable doubt can any longer be entertained, that 
the production of heat by the combustive process is the pur- 
pose to which these substances are destined to be subservient 
in the bodies of herbivorous animals and of man; and the 
results of experience in regard to their relative heat-pr^- 



carpenter's views ox animal heat. 65 

during powers, are in precise accordance with the indica- 
tions afforded by their chemical composition. r * 

It would be interesting to quote the farther argu- 
ments by which this able author defends the posi- 
tion that the amount of oxygen consumed bears an 
exact proportion to the amount of heat evolved, and 
therefore that the former is the true source of the 
latter; but it would occupy too much time at pres- 
ent. I must, however, refer to another view, against 
which Dr. Carpenter argues at some length: — 

"The influence,'' says he, " which conditions of the nerv- 
ous system are shown to possess over the function of calori- 
fication, has led some physiologists and even chemists to 
the conclusion that the production of heat is essentially 
dependent upon nervous agency, of which it is one of the 
manifestations. But, as Prof. Liebig justly observes, Mf this 
view exclude chemical action, or changes in the arrange- 
ment of the elementary particles, as a condition of nervous 
agency, it means nothing else than to derive the presence of 
motion, the manifestation of force, from nothing.' That the 
production of heat in living bodies may take place without 
any possible assistance from nervous agency, is manifest from 
the phenomena of vegetable heat already referred to ; and 
there can be no reasonable doubt that the source of this pro- 
duction is a true combustive process. And the evidence 
afforded by the post-mortem production of heat in the hu- 
man subject conclusively points to the same result; more 
particularly as the elevation of temperature observed in the 
brain was uniformly less than that which was manifested in 
other large organs. But the phenomena enumerated*}* (and 
many others that might be cited) can scarcely be accounted 
for, without admitting that the nervous system exerts an im- 
portant modifying power upon the temperature of the body, 
which may be either elevated or depressed through its agency ; 



* Principles of Human Physiology, Am ed. p. 412. 
f Certain results of experiment and observation on injuries of the 
nervous system in man and lower animals. 



66 LECTURES ON INFLAMMATION. 

and the question now arises whether this operation takes place 
through the influence which the nervous 'system exerts over 
molecular processes of nutrition, secretion, etc., or through 
some more direct method. It can scarcely be denied that 
the first of these channels affords not merely a possible, but 
also a probable, means for the exercise of such influence; 
but still it is difficult to conceive that any great effect can 
be thus produced, since, as already shown, it is not so much 
in the growth as in the disintegration of textures, that heat 
is produced by the oxidation of their components. On the 
other hand, from the close relation which has been shown 
to exist between the vital and physical forces, it can scarcely 
be regarded as improbable that the nervous force, generated 
by molecular changes in the nervous substance, may manifest 
itself under the form of heat, just as we know that it mani- 
fests itself (as in the electric fishes) under that of electricity. 
And thus it is quite conceivable that one mode in which 
alimentary materials may be applied to the maintenance of 
animal heat, may consist in their subservience to these molec- 
ular changes, which seem to take place in the nervous sub- 
stance with more activity than in any other tissue; and thus 
a large measure of caloric may be generated through the 
immediate instrumentality of the nervous system, notwith- 
standing that the ultimate source of its development lies (as 
in the chemical theory) in the oxidation of the elements of 
the food."* 

Dr. Draper, who, like Liebig, inclines to the ex- 
planation of all physiological phenomena upon 
chemical principles, says: — 

" In every instance we assert that the production of ani- 
mal heat is due to oxidation taking place in the economy, 
and giving rise to carbonic acid, water, and other collateral 
products."*}" 

From these views, Dr. Dalton, of New York, in 

his " Treatise on Human Physiology," dissents 

strongly. According to him, — 

"Animal heat is a phenomenon which results from the 

* Op. cit., p. 417. f Human Physiology, p. 182. 



DALTOX'S VIEWS. 67 

simultaneous activity of many different processes, taking 
place in many different organs, and dependent, undoubtedly, 
on different chemical changes in each one. The introduc- 
tion of oxygen and the exhalation of carbonic acid have no 
direct connection with each other, but are only the begin- 
ning and the end of a long series of continuous changes, in 
which all the tissues of the body successively take a part. 
Their relation is precisely that which exists between the 
food introduced through the stomach, and the urinary in- 
gredients eliminated by the kidneys. The tissues require 
for their nutrition a constant supply of solid and liquid food 
which is introduced through the stomach, and of oxygen 
which is introduced through the lungs. The disintegration 
and decomposition of the tissues give rise, on the one hand, 
to urea, uric acid, etc., which are discharged with the urine, 
and on the other hand to carbonic acid, which is exhaled 
from the lungs. But the oxygen is not directly converted 
into carbonic acid, any more than the food is directly con- 
verted into urea and the urates. 

"Animal heat is not to be regarded, therefore, as the 
result of a combustive process. There is no reason for 
believing that the greater part of the food is ' burned J in 
the circulation. It is, on the contrary, assimilated by the 
substance of the tissues; and these, in their subsequent dis- 
integration, give rise to several excretory products, one of 
which is carbonic acid. 

" The numerous combinations and decompositions which 
follow each other incessantly during the nutritive process, 
result in the production of an internal or vital heat, which 
is present in both animals and vegetables, and which varies 
in amount in different species, in the same individual at dif- 
ferent times, and even in different parts and organs of the 
same body."* 

It will be seen that these views, although differ- 
ing from those of Carpenter and Draper, embody 
still the idea of a chemical origin of animal heat. 
And it seems to me that although other molecular 
interchanges besides mere oxidation undoubtedly 

* Op. cit., p. 228. 



00 LECTURES ON INFLAMMATION. 

take place in the tissues, they very generally include 
the latter, and are subordinate to it in their relation 
to the phenomenon we are now studying. 

Permit me to lay before you one other quotation, 
from the "Lemons de Physiologie" of M.Milne-Ed- 
wards, a French physiologist of great authority: — 

"This physiological combustion, as we have seen, takes 
place in all parts of the organism, but not everywhere with 
the same degree of activity ; consequently the mode of dis- 
tribution of the heat in the interior of the animal economy 
may throw some light upon the way in which the chemical 
work of nutrition is shared. In fact, when the thermome- 
trical differences existing between the different parts of the 
body of a bird or a mammal are carefully observed, it be- 
comes at once evident that these inequalities cannot depend 
solely upon the greater or lesser facility with which tlje ani- 
mal heat is sent out among the various organs, but that they 
must depend, in part, upon the local differences in the de- 
gree of activity of the chemical changes in the living tissues, 
which changes give rise to the development of this heat. 
But the study of the varieties in temperature of the differ- 
ent parts of the body is less simple than might at first be 
supposed, since this temperature is influenced by that of 
the parts through which the blood has previously passed. 
In fact, the circulating blood is the grand equalizer of the 
interior temperature of the organism, at the same time that 
it is the alimentive source of the combustion of which the 
evolution of animal heat is a consequence. Our knowledge 
on this subject is as yet but limited ; but according to the 
researches of M. CI. Bernard, we see that the liver is of all 
the organs that in which the molecular movement is the 
most active. 

"In introducing very small and sensitive thermometers 
into different arteries and veins in a living animal, M. CI. 
Bernard has established remarkable differences between the 
temperature of the blood going from the heart to certain 
organs and that which, having traversed these, returns to- 
ward the centre of the circulatory apparatus. Where the 
blood returns from parts exposed to causes of considerable 
chilling, as for instance the limbs, the temperature of the 



HEAT DUE TO COMBUSTION. 69 

venous blood was found to be lower than that of the arterial; 
but where the loss of animal heat is but slight, the temper- 
ature of the blood current was found on the contrary to be 
higher after its passage in the capillary vessels than before 
it reached the interior of the living tissues. This rise of 
temperature was almost always very sensible in the blood 
which had circulated in the thickness of the wall of the diges- 
tive tube, but became still greater after the passage of the 
liquid through the portal system. 

"In vigorous clogs, M. CI. Bernard found the temperature 
of the blood in the hepatic vein to be often 41° (C.) [= 105° 
Fahr.,] or even higher. He found also that the substance of 
deeply-seated tissues was in general hotter than the blood 
passing away from it. 

"It is probable that the kidneys are, like the liver, the 
seat of marked generation of heat, for M. Brown-Sequard 
has found that human urine, at the moment of emission, had 
a medium temperature of 395° (C.) [= 95'1° Fahr.,] and 
was therefore notably hotter than the majority of the organs 
of the body." 

"We have therefore a very great weight of author- 
ity in favor of the combustion-theory of animal heat. 
And I submit that unless it can be shown that in an 
inflamed part there is some superadded source of 
this condition, something which does not exist in 
any degree in the normal state of things, the rise of 
temperature which is observed in inflammation must 
be due to an exaggeration of the combustive process 
proper to health. 

An observation which I have frequently made of 
late lends additional support to this view. In cases 
of hospital gangrene, where one portion of a large 
wound is healthy, or more properly healing, and the 
remainder of it is sloughing, there is a very great 
difference perceived by the hand in the temperature 
of the two regions. The sloughing portion will be 
much hotter than the other. ISTow this process of 

7 



70 LECTURES ON INFLAMMATION. 

sloughing is essentially one of oxidation; for if the 
wound is mechanically cleaned, and a dressing ap- 
plied which will not supply oxygen, while it protects 
the tissue from contact with the oxygen of the air, 
the gangrene will be checked. Here then is an 
actual combustion or burning up of the organized 
elements, with production of heat. 

It must not be forgotten that while, as maintained 
by Dr. Dalton, there are other chemical changes 
going on everywhere in the substance of the tissues, 
there is also in every case oxidation as an essential 
constituent of nutrition and secretion; and hence 
that this latter source of heat can never be done 
away with in the living body. If it were possible 
to isolate the other changes, and to show that they 
were productive of heat when so isolated, it might 
be asserted that oxidation was only one of a number 
of processes by which the temperature was main- 
tained. The ground which I assume to be tenable 
is, that the main source of animal heat is the com- 
bination of other chemical elements with oxygen; 
and that in inflammation the activity of this change 
is so much increased as to render the affected part 
hotter than it normally is. How far other subor- 
dinate agencies are concerned in bringing about the 
same phenomenon, can scarcely be determined ; but 
there is no reason to think that such agencies are 
more than subordinate. A point which will here- 
after be considered is the suspension of the other or 
functional changes in parts which are inflamed, and' 
whose temperature is unduly raised; and this fact 
seems to show that such increase of heat is owing 
to the oxidation, which still goes on. 



LECTURE III. 

PHENOMENA OF INFLAMMATION CONTINUED SWELLING; CAUSED 

MAINLY BY FULNESS OF BLOOD-YESSELS ; ALSO BY ENLARGEMENT 
OF TISSUE-ELEMFNTS. AND BY DEPOSIT OF NEW MATERIAL BETWEEN 
THEM EFFUSIONS — PAIN ; SUBJECTIYE AND OBJECTIYE — ALTERA- 
TION OF FUNCTION — CONNECTION BETWEEN NUTRITION AND FUNC- 
TION — ALL THESE PHENOMENA ARE COEXISTENT, BUT ARE UNEQUAL 
IN PROPORTION CHRONIC INFLAMMATION — ERYSIPELAS INFLU- 
ENCE OF INFLAMMATION ON THE GENERAL BLOOD-MASS — CONSTITU- 
TIONAL SYMPTOMS OF INFLAMMATION, OR SYMPTOMATIC FEVER. 

In my lecture of last week, I endeavored to set 
forth the rationale of the abnormal heat and red- 
ness which mark the state of inflammation; taking 
the ground that the former phenomenon was due to 
the more abundant circulation going on in the part, 
and that this found its explanation, not in any force 
exerted by the vessels, or in their debility or relax- 
ation, but in the augmented attraction of the tissue- 
elements for substances contained in the blood. As 
to the rise of temperature, it will be remembered 
that it was ascribed to the abnormally increased 
activity of the combustion which in the state of 
health is the source of animal heat. 

"We have now to take up for study the third of 
the phenomena of inflammation, — the swelling. And 
it needs no very extended observation to show that 
this symptom varies much in its degree in different 
cases. Some tissues swell much more quickly, and 



72 LECTURES ON INFLAMMATION. 

to a greater extent, than others — mainly because the 
mechanical obstacles are less. Wherever parts are 
bound down by strong and inextensible fasciae, or 
are themselves dense and firm in structure, the de- 
gree of actual swelling will be less, but the effort at 
its production will be the same; and the tension 
thus caused often gives rise to very severe suffering. 

One cause, and the most obvious one, of this 
swelling, is the fulness of the blood-vessels. The 
existence of such an abnormal fulness has already 
been pointed out; that it is competent to give rise 
to swelling, is clear from the fact that the same re- 
sult follows from purely mechanical distension, as 
for example when a string is tied around the finger 
so as to arrest the flow of blood through the veins. 
Another instance more to the point is to be found 
in the swelling which accompanies physiological 
congestions, as in the case of the erectile tissues. 
Here the amount of swelling is often very great, 
and can only be explained as due to the gorging of 
the vascular system of the part, since by means of 
minute injections, we can artificially imitate in the 
dead subject the distension of the vessels, and pro- 
duce a similar swelling. 

There is, it may be, a stage of inflammation in 
which the fulness of the vessels is the sole cause of 
the swelling which exists; but so far as we know, 
this is only the very earliest stage. Perhaps it 
might even be more properly called a preparatory 
or transition state between health and actual in- 
flammation ; so that if the morbid process were 
arrested at this point, and the normal state of things 
restored, inflammation would not really have oc- 



CAUSE OF AFFLUX OF BLOOD. 73 

curred at all. And here the distinction may again 
be drawn between mere hyperemia, such as might 
result from mechanical causes, and the congestion 
which is due to increased activity of the life-actions 
of the part, whether physiological or pathological. 
In the first case, as for example when a string is 
tied around the finger, the whole of the distal por- 
tion of the finger will be equally affected by the 
backing up of the venous current. In the second 
case, the extent of the congestion is determined by 
that of the influence of the exciting cause. For 
instance, in any of the erectile tissues, the change 
of condition affects all the parts of a certain system. 
It is not only the penis that becomes enlarged and 
congested in sexual excitement, and this by the 
mere pressure of the erectores muscles over the 
veins, but there is an increased flow of arterial 
blood into the organ, and this takes place also in 
the scrotum and testes. 

Evidently there is here, in physiological language, 
a consensus of parts, and not a mere accumulation 
of blood such as takes place from a mechanical 
cause. And I contend that a state like this must 
involve the existence of a vis a fronts, an attraction, 
the limits of which are determined by those of the 
function concerned. 

If now we substitute for the normal and physio- 
logical stimulus a pathological one, this also will 
influence the parts to a certain extent and degree in 
each case. And by the extent and degree of this 
influence will be determined the extent and degree 
to which the attraction of the tissues for the blood 
shall be augmented. Hence will ensue, first, a fill- 

7* 



74 LECTURES ON INFLAMMATION. 

ing of the blood-vessels of the part upon which the 
disturbing cause acts, and a proportionate amount 
of swelling. Such a course of things is very com- 
monly seen when a splinter gets into the skin. All 
around the point of injury the vessels fill with blood, 
and soon a little territory of redness and swelling is 
noticeable. If the foreign body be withdrawn, the 
congestion will very probably pass off, and the red- 
ness and swelling disappear, in a short space of time. 

There are two other possible sources of swelling 
besides this filling up of the blood-vessels. One is 
an increase in the size of the tissue-elements of the 
affected part; the other is the deposit of new ma- 
terial between them. 

Let us first inquire into the degree of importance 
to be assigned to the former of these conditions. 

Any increase in the size of the tissue-elements 
must be due either to an actual process of growth 
in them, or to an infiltration into them of some 
material not nutritive in its character. But although 
such growth might take place in the stage of mere 
irritation, it is contrary to what we know of the 
effects of inflammation upon the powers of life to 
suppose that it can go on when the latter state is 
fully developed. A part which is inflamed is always 
weakened; that is, it is less able to fulfil its func- 
tion, less able to resist any disturbing or destructive 
influence. Examination of such a part, either in its 
grosser anatomy or under the microscope, always 
reveals a deteriorated condition of the tissues com- 
posing it. Hence the idea of a true growth as a 
constituent phenomenon of inflammation may be 
rejected. 



SWELLING FROM EFFUSION. 75 

The only material which the tissue-elements could 
take up by mere infiltration so as to increase their 
size, is serum. I have never seen this, and in fact 
do not know whether its occurrence could be a mat- 
ter of observation, although it is conceivable. And 
it could not be of much importance, except as hin- 
dering still further the already impeded function of 
the part. 

The third condition mentioned as giving rise to 
swelling is of more moment than either of those 
which have now been considered. It is the extrav- 
asation, or escape from the vessels, either of blood 
as such, or of some of its constituents, or of the 
peculiar substance so well known under the name 
of pus. 

Those constituents of the blood which may escape 
are either the watery and saline portions, — the 
serum, or the fibrinogenous, thicker liquid, — the 
lymph. As to the former, it may readily be dis- 
posed of, so far as our present inquiry is concerned, 
since its effusion is neither constant in inflamma- 
tion, nor necessarily an evidence of that state. Mere 
mechanical causes may give rise to its pouring out, 
as for instance in anasarca; and the probability is 
that it is never dependent on any other condition. 
"WTien in any case it accompanies inflammation, it 
gives to the swelling the doughy character of 
oedema; and this is apt to occur in certain parts, 
such as the ocular conjunctiva, the prepuce, and 
the labia in women. In each of these cases, the 
tissues concerned are of a loosely fibrous structure; 
and when, in old or weakly persons, parts usually 
dense and firm become relaxed and flabbv, the 



76 LECTURES ON INFLAMMATION. 

swelling in any inflammation which may occur will 
in like manner be oedematous and yielding. How 
far in such cases the effusion of serum may be sub- 
stituted for that of lymph, or to what degree the 
two substances may coexist, can scarcely be defined. 
Probably, however, such a substitution is possible; 
or rather, the blood being poor in quality, and the 
tissues possessed of but small formative or assimi- 
lative force, the serous portions of the blood only 
escape. In other cases, the blood being richer, and 
the tissues having more energy, an effusion of 
lymph, diluted by an admixture of serum, may be 
readily conceived of as taking place. 

The special point to be noted is, that these effu- 
sions are not of a different nature, as are alcohol 
and water, but that one passes imperceptibly into 
the other, so that in fifty instances of inflammatory 
exudation, the material poured out might present 
as many different degrees of richness, pure serum 
being at the lower end of the scale, and pure lymph 
at the higher. 

Let me say here that in the foregoing remarks I 
have made use of expressions, such as " effusion," 
" poverty and richness," and •" formative force," 
which have a certain conventional value, but which 
must not be regarded as scientifically accurate. It 
will hereafter be our business to look into the sub- 
ject of the origin and development of lymph, and 
then the force of these expressions, and their rela- 
tion to the processes and qualities denoted by them, 
will be more readily estimated. 

The swelling in inflammation is therefore due 
primarily to the fulness of the blood-vessels; in the 



paix. 77 

second place, to the formation of a new substance 
called lymph, which crowds apart the normal tissue- 
elements; in the third place, perhaps, to an enlarge- 
ment of those elements. Fourthly, it may be in- 
creased by the escape from the vessels of the watery 
portions of the blood, which may either dilute the 
lymph, or take its place altogether. Fifthly, if the 
vessels are in any way ruptured, there may be a 
haemorrhage of more or less extent. Of all these 
causes of swelling, the only one which is constant 
is the first. The increase in size of the elements of 
the tissue is probably infrequent, and does not be- 
long properly to the inflammatory process. The 
formation of lymph is apt to occur, but is not in- 
variable, while the effusion of serum, like that of 
blood, is a mere accident. 

One other condition of inflammatory swelling 
remains to be spoken of, — the development of pus. 
This, however, is unimportant here, except as modi- 
fying the shape and character of the enlargement; 
the shape, because it seeks the surface, and causes 
what is known as " pointing," the character, because 
its presence gives rise to fluctuation. 

Pain, as a symptom of inflammation, is almost 
constant. It is wanting in some cases where the 
sensibility of the nervous system is lessened, and in 
others where that of the part involved is not natu- 
rally acute. Thus in old and imbecile persons, 
pneumonia may run its course to disorganization of 
a large portion of the lung-tissue without producing 
pain enough to call attention to the disease. A 
case of gunshot wound of the chest, the ball being 
imbedded near the apex of the left lung, which was 



78 LECTUEES ON INFLAMMATION. 

almost destroyed by the resulting inflammation, has 
recently occurred under my notice. Prom first to 
last, a period of more than four months, the patient 
made no complaint of pain. 

This symptom is always marked where the struc- 
ture of the part is such as to prevent free swelling. 
And hence it may be inferred that it is in great 
measure due to the pressure of the swollen tissues 
upon the terminal nerve filaments. 

Another important source of pain is probably the 
heat evolved in the part by the abnormally active 
chemical changes going on among its elements. 

Besides these causes acting from without, there is 
reason to believe that the nerve-fibrils are not only 
so involved in the abnormal process as to be mor- 
bidly sensitive, but so changed as to become the 
seat of subjective pains. Special sense seems to be 
abolished, where it exists in health, and the only 
capacity of the nerves distributed to the affected 
part seems to be for pain. 

That the character of this symptom varies greatly 
in different cases, is a fact of which almost every 
one is aware from experience. It is aching, burn- 
ing, stinging, itching, more or less severe, according 
to the part involved, the violence of the disorder, 
and the sensitiveness of the patient. 

Where the terminal nerve filaments are in rela- 
tion with a surface, as in the skin, the pleura, or the 
peritoneum, the pain is apt to be greater than w r here 
they are distributed through the mass of a solid 
organ such as the lung, liver, or spleen. 

The singular fact has been often observed, that 
in some inflammations the pain is referred to a spot 



MISPLACED PAIX. 79 

at a distance from the actual seat of disease. Thus 
in coxalgia the knee is apt to be complained of, in 
the early stages at least of the affection. This cir- 
cumstance finds its explanation in the distribution 
of the nerves which are the seats of the morbid 
feeling, and which, supplying but few terminal fila- 
ments to the point actually disordered, communi- 
cate to the cerebro-spinal axis the same impression 
as if the trouble lay at their final expansion. Some- 
thing similar occurs when the ulnar nerve is com- 
pressed in its passage behind the inner condyle of 
the humerus, when the distress felt is all in the parts 
supplied by the nerve in its ulterior course. This 
transference of sensation is never met with, I be- 
lieve, where the parts actually involved are such as 
when in health possess much tactile sensibility. It 
is to be specially noted that in such cases the pain 
is not of the ordinary character of that of inflam- 
mation, but is more neuralgic; patients who are old 
enough describe it as gnawing and wearing. An- 
other fact of importance is that the pathological 
state of the hip -joint which gives rise to such pain 
is often, perhaps indeed in a very large majority of 
cases, not strictly speaking an inflammation; this 
condition may be developed to some extent as an 
incidental phenomenon, but the disease itself is a 
mere outcropping of a vice of constitution. I am 
aware that the doctrine is strongly advocated by 
some surgeons of experience, that the disorder in 
question is always produced by injury, but although 
this may be the exciting cause, there is strong 
ground for the belief that it merely gives a provo- 
cation, and calls forth, in a certain direction, tend- 



80 LECTURES ON INFLAMMATION. 

encies which had lain dormant in the economy. 
Certain it is, that the scrofulous diathesis — to use 
a conventional term — is often strongly marked in 
persons who are the subjects of hip-joint disease. 

In almost all cases of inflammation there is posi- 
tive and continual pain; but when this does not 
exist, there is tenderness, either upon pressure or 
upon motion. In pneumonia, for instance, the act 
of deep breathing develops pain; in inflammation 
of loose and yielding parts, pressure does the same. 

The pulsatile or throbbing character of inflam- 
matory pain may be readily understood. A con- 
gested state of the vessels of a part, by which they 
are crowded against the resisting structures about 
them, will cause each beat of the heart to make 
itself felt, especially when the undue sensitiveness 
of the nerve-fibrils, which constitutes an element of 
the morbid state, is taken into the account. 

One other symptom of inflammation, which ought 
perhaps rather to be regarded as an effect of all the 
others now mentioned, remains to be noticed, — the 
alteration of function. During the irritative or pre- 
liminary stage, the function may be performed in 
excess; as the process goes on, it is interfered with 
and set aside; and still later, it may be restored, but 
not in its healthy character. 

This alteration of function, either in the way of 
abolition or impairment, may be due either to me- 
chanical causes, or to such structural changes as 
necessarily attend the morbid process. Perhaps it 
would be more correct to say that the structural 
changes, in all cases of true inflammation, lie at 
the root of the disorder of function, which is 



ALTERATION OF FUNCTION- 81 

brought about either mechanically or chemically. 
For although functional disorder may occur with- 
out any positive evidence of any morbid change of 
structure of the part, we cannot for a moment sup- 
pose that such change of structure can occur with- 
out being attended with derangement of function. 
An assemblage of chemical elements is endowed 
with a certain corporate power, by virtue of which 
the affinities of each are in no way suspended or 
abolished, but simply conjoined with those of all 
the rest for the attainment of a common end. Now 
it is no more possible for one of these chemical ele- 
ments to be altered without influencing the aggre- 
gate result, than, to bring up again my army simile, 
for one man or ten men in a company to be demor- 
alized without so much beins; detracted from the 
efficiency of that company; and the evil may spread 
much further if those men by their example and 
conversation infect their comrades. 

We are speaking now of the performance of func- 
tion; and if the structure and composition of the 
cell are, as it seems but common sense to assume, 
intimately connected with, and essential to the end 
which the cell is intended to answer, any change in 
that structure or composition must at once affect 
the fitness of the cell to its end. 

Allusion has before been made to the intimate 
connection existing between nutrition and function. 
But in the state of inflammation two of the most 
important elements of nutrition are materially in- 
terfered with — the supply of blood is in excess, 
while the assimilative power of the tissues is les- 
sened, and the influence of the nervous system is 

8 



82 LECTURES ON INFLAMMATION. 

changed just so far as the terminal nerve-filaments 
are involved in the disease, or affected secondarily 
by its phenomena. Hence, exactly to the degree in 
which these abnormities are developed, will the pro- 
cess of nutrition and its close dependent, function, 
be impaired. 

Now in speaking of the general subject of animal 
heat, I took the ground that the temperature of the 
living body was kept up by the chemical changes 
going on in the tissues, and especially by those true 
combustions which result in the formation of car- 
bonic acid, water, and ammonia. But as these very 
changes are closely linked with, and essential to, 
the functions of all the organs, it might seem as if, 
when function w T as impaired or set aside, the heat 
of the affected part ought to fall, from the failure 
of its source. Common observation, however, tes- 
tifies that the temperature rises, while we know also 
that function is interfered with. How is this seem- 
ing inconsistency to be explained? I think, simply 
by the fact that the oxidation or combustion goes 
on more actively, while the other and more special 
interchanges of material between the blood and the 
tissues are either hindered or checked altogether. 
Oxidation is indeed essential to function, and closely 
interwoven with it — but the latter does not neces- 
sarily ensue upon the former. "When a function is 
performed, we may assert most positively that there 
has been an oxidation and burning up of the tissues 
concerned in its performance; but we now know 
well that such a combustion may take place, and 
yet the function fail. 

There is an error into which those who are look- 



ORDER OF PHENOMENA. 83 

ing into this matter for the first time are particu- 
larly apt to fall, although it may seem as if it were 
easy to avoid it. It is that of regarding these phe- 
nomena of inflammation, — the redness, heat, swell- 
ing, and pain, and the impairment of function, as 
successive in their occurrence ; whereas they are all 
in existence at one and the same time, and are only 
studied separately for the sake of convenience. Let 
us try now to correct this error so far as it may have 
arisen in our inquiry. 

The heat and pain attract the patient's notice 
first, generally, and the swelling is then perceived; 
sometimes, in parts which have mechanical rela- 
tions with the flexure of a joint for instance, the 
swelling makes itself felt at the same time. The 
redness, in superficial parts, seems to be developed 
simultaneously with the heat and pain, while, ex- 
cept in the case just mentioned, the swelling is the 
last symptom to appear. Very often the impair- 
ment of function is almost or quite overlooked by 
the patient, seeming to be eclipsed in importance 
by the other phenomena. 

But although, so far as the sensations of the 
patient and the casual observation of a bystander 
can be relied on, there seems to be a difference in 
point of time in the occurrence of the phenomena 
of inflammation, such an idea is at variance with 
the explanations of those phenomena before given. 

For, the part being irritated, the morbid process 
begins in an entirely excessive and abnormal at- 
traction of blood to it by the tissues; the vessels 
become more and more turgid, combustion goes on 
more and more rapidly, the nerve -filaments are 



84 LECTURES ON INFLAMMATION. 

altered in condition and subjected to greater and 
greater pressure; while the tissues in which these 
morbid changes are taking place are less and less 
duly nourished, and more and more impeded in the 
performance of their function. 

Surely in all this there is no succession, but the 
causes of the heat and redness, of the swelling and 
the pain, arise together, some of them being the 
same; and the part, from the moment of its mani- 
festing any change from the healthy state, goes on 
becoming less and less fit for its duty until the dis- 
ease has reached its height. 

But while the symptoms of inflammation are thus 
uniform in the actual time of their occurrence, they 
are less so in their proportion. Perhaps the heat 
and the redness are more nearly constant in their 
relative degree than any other two of the other phe- 
nomena, and this for an obvious reason, in their 
common origin. The amount of pain is much more 
variable, and the swelling may range anywhere be- 
tween scarcely perceptible enlargement and extreme 
deformity. To a certain degree, the swelling and 
the pain may be said to be in an inverse ratio; for 
when from mechanical conditions the swelling is 
limited, the pressure upon the nerve-fibrils is neces- 
sarily more severe. Another qualifying circum- 
stance must, however, be mentioned; in some parts 
the nerves are so much more sensitive than in 
others as to be affected far more severely by a given 
amount of pressure. 

The description and remarks now given do not 
apply to the state of chronic inflammation, in many 
respects. What the differences are between the 



CHRONIC INFLAMMATION. 85 

acute and chronic forms of the disease, may per- 
haps be as well set forth here as at any other stage 
of our discussion. 

Chronic inflammation offers the same features 
as the acute, but differently proportioned one to 
another. There is always more or less redness, 
often very marked, sometimes of a deepness almost 
amounting to purple ; but the color is apt to be 
more evenly spread, and less inclined to heighten 
about a focus than in the acute form of the disease. 
As a general rule, the heat is very much less devel- 
oped, although, while the actual rise of temperature 
is less, the subjective sensation of burning may be 
extremely troublesome. Swelling is usually pres- 
ent, but like the redness it is more diffused than in 
acute inflammation; it is sometimes very marked 
in its degree, and is then often cedematous, and of 
a manifestly passive or mechanical origin. Pain is 
in many cases wholly wanting, or only slight, but 
there may be a good deal of tenderness. Function, 
if mechanical, is apt to be abolished; if it consist 
in secretion, it is more commonly disordered. 

It would be easy, if time were less valuable, to 
go in detail into the rationale of each of these phe- 
nomena of chronic inflammation, and to show that 
they corresponded altogether in this respect with 
those of the acute. By analogous facts and argu- 
ments, we should find the redness to be due to ful- 
ness of the blood-vessels, the swelling to the same, 
with the addition of effusion; the objective heat to 
augmented rapidity of chemical change, the subjec- 
tive to the state of the nerve-fibrils within the part, 
to which the pain would also be found attributable. 

8* 



83 LECTURES ON INFLAMMATION. 

Chronic inflammation, whether it is an original 
or a secondary form assumed by the disease, is 
easily explained upon well-known principles. Its 
slight severity as compared with the acute, is due 
of necessity to a difference either in the exciting 
cause or in the part affected. Thus the condition 
which gives rise to it may be of gentle but con- 
tinuous action, — or, the original disturbance having 
been severe, there is a tolerance acquired by the 
tissues which lessens very much the degree to which 
they are irritated by it. Such a tolerance may be 
manifested either by the nerves of the part or by 
its organic elements. And this explains the dimi- 
nution of all the phenomena when an inflammation 
becomes chronic. The grade of all the morbid 
changes which take place in the part is lowered. 

One or two points must be specially touched upon 
in this connection. The redness sometimes remains 
very marked; and in all cases it is readily increased 
by any renewed irritation. The cause of this is to 
be found in an actual change in the relative size of 
the capillary vessels and the tissue-elements. Pas- 
sive as the vessels still are, they are distended in 
the state of acute inflammation, and, the part not 
returning to absolute health, no force is exerted 
upon them to restore their normal size. The tissue- 
elements are still impaired in their nutrition, and 
their bulk is probably often diminished; while the 
excitement which first augmented the attraction 
they exert upon the blood is still kept up, although 
perhaps in a greatly less degree. 

I have had occasion to speak of the tolerance 
acquired by the tissue-elements as well as by the 



DIMINUTION OF POWER. 87 

terminal nerve-filaments, when an irritation is long 
kept up. This is entirely consistent with another 
fact, viz., that any new stimulus makes itself felt 
more severely than it would if applied to the healthy 
organ. And this irritability is associated, in the 
case of the individual tissue or part, with diminished 
power of life, just as it is in the aggregate or system 
at large. As every one knows, a man whose strength 
is broken down by disease, inflammatory or other- 
wise, is more readily disturbed by any morbific 
agency than he was when in health. The quick- 
ness and intensity with which he feels any such in- 
fluence is in fact proportioned, not to his vigor, but 
to his weakness. 

By this expression, power of life, we mean the 
tenacity with which the corporate character before 
alluded to as possessed by organized matter, and 
the energy with which the functions belonging to 
that corporate state are exercised. It is the essence 
of this which is beyond human understanding; its 
mode of manifestation is easy to observe. 

We have now surveyed the phenomena of inflam- 
mation, which were laid down as essential to it, — 
and have inquired into the rationale of those phe- 
nomena. I would once more insist upon the position 
which I took in my first lecture as to the identity 
of this process, whenever and wherever it occurs. 
Such a theory does not conflict with the fact that 
the grosser characters of the disease may be modi- 
fied by its causes, by states of the system, by the 
anatomical structure of the affected part, or b}^ pecu- 
liarities in its normal constitution, by sanitary or 
remedial measures. 



88 LECTURES ON INFLAMMATION. 

The inflammation which surrounds a small-pox 
pustule is identical, in my opinion, with that which 
affects the skin when a foreign body imbedded in it 
is the source of the mischief. It is essentially the 
same as that which, occurs in the brain, the lung, or 
the bladder. In every one of these instances we 
have the same phenomena, the heat, redness, swell- 
ing, pain, and impairment of function. Whatever 
other conditions may be present are secondary and 
incidental to these principal ones. 

To look a little further into this. Take a case 
of cystitis, or inflammation of the urinary bladder. 
Here there is a copious deposit in the urine of pus 
and mucus, with epithelium from the lining mem- 
brane, and phosphatic crystals. There is much 
distress in micturition, and in the performance of 
function by the other abdominal viscera. The nerv- 
ous system may be greatly disturbed by the suffer- 
ing undergone. But all these symptoms, and any 
others which I may have omitted to speak of in this 
hasty enumeration, are simply incidental to the in- 
flamed state of a part or the w^hole of the urinary 
bladder. And the disease lies in that layer of the 
wall of this hollow organ which intervenes between 
the muscular coat and the mucous membrane. Here, 
upon examining after death, we lind developed the 
physical characters of inflammation — and it is easy 
to see that with these the heat and pain, and the 
impaired function, were intimately associated during 
life. 

To a want of rigid accuracy in the separation of 
the essential phenomena from their secondary con- 
sequences, may be attributed much of the obscurity 



ERYSIPELAS. 89 

which still clothes this subject. Unless it can be 
shown, that there is an essential difference between 
the process of inflammation as manifested in differ- 
ent organs, or under what have been called its dif- 
ferent forms, we must believe that here as elsewhere 
in nature the law of simplicity of type is adhered to. 

I can scarcely leave this subject without alluding 
to one point which seems to me important, and 
which may be better spoken of in this connection 
than elsewhere. 

Among the various forms of inflammation men- 
tioned by Hunter, was the erysipelatous. Now there 
is at first sight great propriety in calling erysipelas, 
as well as the erythema which is so often confounded 
with it, a form of inflammation. But I submit that 
a closer scrutiny will show that erysipelas is a special 
disease, which excites inflammation as an incidental 
condition, — and which, moreover, modifies this con- 
dition to a marked degree. Put the poison of ery- 
sipelas in relation with the system, or with certain 
parts which are readily influenced by it, and it gives 
rise to an inflammatory change in the nutrition, the 
symptoms of which differ in their relative propor- 
tion from those of the same process as excited by 
the presence of a foreign body. But, and herein 
lies the point for which I argue, the starting-point 
of the difference is not in the inflammation itself, 
but in the cause. And hence, although we may 
with propriety speak of erysipelas as a disease, or 
of inflammation as one of its invariable but inci- 
dental phenomena, we cannot use the term erysipe- 
latous inflammation correctly, except in a wholly 
conventional sense. 



90 LECTURES ON INFLAMMATION. 

Your attention has now been directed to the phe- 
nomena which are essential to the process of inflam- 
mation, as they exist in their full development. 

Upon reviewing the ground over which we have 
passed, I think it will appear that these phenomena 
all depend on the tissues for their origin and main- 
tenance. The gorging of the vessels with blood, it 
was argued, was due to an influence exerted by the 
organic elements or cells upon that liquid; redness 
was thus produced, and swelling, the latter being 
also due to certain effusions. The heat was ascribed 
to chemical changes going on between the blood 
and the tissues, and the pain to morbid alteration 
of the nerve-fibres and the relation between them 
and the surrounding parts; while the function must 
of necessity owe its disorder to some abnormal state 
of the agents Avhich carry it on in health, — the tis- 
sue-elements. 

We leave out of the account, therefore, all the 
notions which have prevailed so widely among 
writers on pathology in regard to " action of the 
vessels." The question of contraction or relaxation 
of the capillaries, primary or secondary, is wholly 
immaterial. Those tubes are neither strengthened 
nor weakened, but simply, as in health, passive — 
yielding to a pressure from within when the current 
flowing along them is increased in volume, and in 
like manner yielding to a pressure from without 
when that current becomes smaller. 

Such, at least, seems to me to be the legitimate 
result of the reasoning we have employed in the 
interpretation of our facts. Nor do I know of any 
fact in support of other theories, or which has ever 



CHANGES Of THE BLOOD. 91 

been §o adduced, which has been overlooked in our 
inquiry. It is in the tissues that the true theatre of 
the inflammatory process is to be placed. They are 
the seat of the healthy life-actions, and when the 
character of those actions is changed so as to con- 
stitute disease, it is still in the tissues that the 
change resides. In either case, the material struc- 
ture is wholly passive, and normally or abnormally, 
obeys the influences exerted upon it. 

Upon the views which have been presented in 
regard both to normal nutrition and to inflamma- 
tion, it must be obvious that according to the extent 
and degree of the latter there will be a change 
wrought in the character and composition of the 
blood. For in health the relation between any 
organ or mass of tissue and the blood flowing 
through it is, as has been already said, one of in- 
cessant interchange. To use the expression of Tre- 
viranus, quoted by Paget, every part stands to all 
the rest in the character of a secretion. More than 
this, it throws into the blood again the materials 
which have resulted from its own waste. And 
should the amount of material taken or given by it 
be altered in quality or quantity, the relation it 
bears to the blood contained within its vessels is in 
a corresponding degree altered. But as this blood 
is carried on in the course of the general circula- 
tion, and the supply continually renewed to the 
affected part, it is clear that a certain influence must 
be exerted upon the whole blood-mass of the econ- 
omy. In the case of a large part or organ, it may 
be readily seen that the effect so produced would 
be appreciable — while if the extent of the abnormity 



92 LECTURES ON INFLAMMATION. 

were but small, the change in the general blood- 
mass, although no less real, would be too slight to 
make itself felt. 

Again, there are some organs which have special 
functions to perform in modifying the composition 
of the blood. Such are, for example, the lungs, the 
lymphatic glands, the spleen. Inflammations of 
these organs would naturally be supposed to affect 
the blood more directly than would those of other 
parts. And it is found by experiment that such is 
the case ; although the opportunity for observation 
has not as yet been extensive enough to give accu- 
rate data in regard to all the points embraced in 
this statement. 

When, therefore, we come down from these gen- 
eral facts to the special enumeration of the blood- 
changes which occur in inflammation, we meet with 
great difficulties. Notwithstanding the labor that 
has been spent in the study of this subject, the most 
earnest and skilful investigators have been foiled in 
their endeavors to clear it up. All that is known 
in regard to it may be soon stated. 

The red corpuscles of the blood drawn from any 
one laboring under inflammation show, when ex- 
amined under the microscope, a tendency to adhere 
one to another by their flat sides so as to form 
rouleaux. This phenomenon is observed also in 
the case of pregnant women, and in horses as a 
normal condition. No satisfactory explanation of it 
has ever yet been offered, but as Paget remarks, it 
would seem to belong not to the blood in the ves- 
sels, but to that which has been removed from the 
sphere of life. When it exists, it is one cause of 



CHANGES IN THE BLOOD-CORPUSCLES. 93 

the formation of the buffy coat, — the whitish or 
pale yellow layer at the surface of the blood-mass ; 
the specific gravity of the rouleaux being greater 
than that of the same number of reel corpuscles 
would be if scattered apart, so that they sink rapidly, 
leaving a portion of the clot uncolored. 

The number of red corpuscles in the blood is 
probably diminished in inflammation, if it is altered 
at all. For in view of the close mutual relation 
between the blood and the tissues, it is difficult to 
. see how the nutrition of the latter can be disturbed 
without affecting that of the former. And it is 
equally difficult to imagine that the nutrition of the 
blood can be interfered with, without each of its 
constituents sharing in the trouble. But the red 
corpuscles are the most highly developed of those 
constituents; their presence is the main feature of 
the distinction between blood and lymph, and in 
the condition recognized as poverty of the blood, 
they are diminished in quantity. Whether or not 
they are only the colorless corpuscles in a highly 
developed state, physiologists do not agree ; the 
evidence does not seem to me to favor such an idea. 

As to the white corpuscles, it may be regarded 
as certain that their number is very much aug- 
mented in many inflammations; and the same may 
be said, with less reservation, of the fibrin. I men- 
tion these two constituents of the blood together, 
because the fact has long been recognized that they 
bear a certain relative proportion to one another, 
and that they cannot be separated with any exact- 
ness in our investigations. To quote again from 
Yirchow : — 

9 



94 LECTURES ON INFLAMMATION. 

"It is very rarely that a considerable increase of fibrin 
takes place without a simultaneous increase in the colorless 
blood-corpuscles, and therefore the two essential conditions 
which we meet with in the lymph, we again meet with in 
the blood. In every case of hyperinosis we may rely upon 
discovering an increase in the colorless corpuscles; or, in 
other words, every irritation of a part, which is abundantly 
provided with lymphatics, and freely connected with lym- 
phatic glands, occasions also the introduction of large num- 
bers of colorless cells (lymph-corpuscles) into the blood.' 7 

The idea has been entertained by some observers, 
that the increase now alluded to of the colorless cor- 
puscles and the fibrin, was a local change, or rather 
that only the blood flowing through the affected part 
was involved in it. But the weight of modern author- 
ity, that of Jones, Bennett, Yirchow, Paget, Follin, 
and in fact of most writers of our day, is in favor of 
the idea that the whole blood-mass is modified in 
this way. 

It is by microscopic examination that we ascer- 
tain the abnormal quantity of the white corpuscles 
in the blood. The increase in the amount of fibrin 
is shown by the size and tenacity of the clot formed 
in the blood when drawn. And here perhaps it 
may be best remarked that while the former condi- 
tion must obviously exist in the blood as it flows 
along the vessels, the latter is considered by many 
physiologists as occurring after the blood is with- 
drawn from the sphere of life. "With this question, 
however, we are not now concerned — the fact of the 
increase stated is beyond a doubt. According to 
the analyses of Andral and Gavarret, Simon, and 
other observers, the amount of fibrin, normally 3 
parts in 1000, is augmented in inflammation to 4, 
5, or 6. 






CHANGE IX FIBRIX. 95 

Besides the change in quantity of the fibrin, it 
has been mentioned that its coagulation takes place 
more firmly than in health, — and this fact was for- 
merly considered as an evidence of greater organiz- 
ing power. But the position of fibrin in regard to 
organization is now thought to be unimportant, the 
idea that it was albumen undergoing developmental 
change having been abandoned; and it is considered 
rather as a result of degeneration. And this is 
clearly in agreement with another view of recent 
origin, viz., that inflammation itself is not a state of 
increased, but of diminished vigor. 

Permit me again to quote from Virchow some re- 
marks in relation to this increase in the amount of 
the fibrin and colorless corpuscles in inflammatory 
blood. He says, in connection with an argument 
for the local origin of all these changes in the gen- 
eral blood-mass : — 

" Those organs which with especial frequency exhibit this 
peculiar combination of a so-called phlogistic state of the 
blood with a local inflammation, are generally abundantly 
provided with lymphatic vessels, and connected with large 
masses of lymphatic glands, while all those organs which 
either contain very few lymphatics, or in which these vessels 
are scarcely known to exist, do not exercise any influence 
worth naming upon the amount of fibrin in the blood. For- 
mer observers had already remarked that there were inflam- 
mations occurring in very important organs, as for example 
in the brain, in which the phlogistic crasis was, properly 
speaking, not at all met with. Now it is precisely in the 
brain that we have scarcely any evidence of the existence 
of lymphatics. In those cases, on the contrary, in which 
the composition of the blood is earliest altered, namely in 
diseases of the respiratory organs, we find an unusually 
abundant net-work of lymphatics. Not merely the lungs 
are pervaded by, and covered with them, but the pleura also 
has extremely numerous connections with the lymphatic sys- 



96 LECTURES ON INFLAMMATION. 

tem, and the bronchial glands constitute almost the greatest 
accumulations of lymphatic -gland -substance possessed by 
any organ in the whole body." 

The amount of albumen in the blood seems to be 
increased by the occurrence of inflammation, al- 
though not in so exact a proportion to the fibrin as 
would be supposed upon the idea which prevailed 
until recently, that the latter was developed from 
the former. 

Along with the diminution of the number of red 
corpuscles, and the increase in the amount of fibrin, 
albumen and colorless corpuscles, in inflammatory 
blood, the quantity of water is increased. From 790 
parts in 1000 it often, in the analyses reported by 
Simon, in his " Chemistry of Man," rose to over 
800. At the same time the salts held in solution 
were greatly lessened. The rationale of these facts 
I am not prepared to give, nor is it perhaps im- 
portant. 

To sum up then the changes which are observed 
in the blood of persons laboring under inflamma- 
tion, and which, according to the views I have at- 
tempted to set forth, are due in great measure to 
the influence of that local condition, — the red blood- 
corpuscles are diminished, as are also the salts ; 
while the white corpuscles, the albumen, the fibrin, 
and the water are largely increased. 

And without entering into detail, I may again 
say that these changes are in some degree influ- 
enced by the normal function of the part concerned. 
Thus, according to Simon's analyses, both the albu- 
men and the fibrin were found to be increased in 
larger proportion in pneumonia and peritonitis than 






CONSTITUTIONAL SYMPTOMS. 97 

in other inflammations. In phthisis also the albu- 
men was largely increased, the fibrin less so ; but it 
is not certain how far the vice* of constitution in 
this disease modified the effect of the incidental 
inflammation. 

The occurrence of inflammation is generally at- 
tended, — always if the part involved is large or 
important, and especially if the disturbance is sud- 
denly brought about, — by a more or less severe de- 
rangement of the system. And it is obvious that 
no examination of the phenomena of this disease 
can be complete without embracing the symptoms 
which are thus secondarily induced. Having there- 
fore discussed the local changes involved in inflam- 
mation, and those which ensue upon it in the general 
blood-mass, let us now take up the subject of irrita- 
tive or symptomatic fever. 

Peculiar difficulties invest the study of all consti- 
tutional diseases. Their mere phenomena are not 
hard to define, but to trace these to their several 
sources, and to point out their relations of cause 
and effect, so as to form an accurate idea of the 
whole process, is beyond our present powers of anal- 
ysis. In proof of this it is sufficient to refer to the 
whole class of fevers. We know, perhaps as exactly 
as we ever shall, the natural history of the various 
types of fevers, and of the several members of each 
group; we can state the lesions apt to be associated 
with each. But after all the earnest and careful 
study bestowed on these disorders by intelligent 
observers in various countries, many important 
questions in regard to them are still unsettled. 
For example, nothing is definitely known of their 

9* 



98 LECTURES ON INFLAMMATION. 

causes. When malaria is spoken of, it is a mere 
conventional expression ; so also is contagion. No 
one has ever yet been able to give anything like an 
accurate description of the nature or mode of oper- 
ation of either. 

And when we consider the constitutional irrita- 
tion produced by local inflammations, we find that 
the greater simplicity of this morbid state does not 
make it any more easy of real comprehension. 

Fever is a condition so often met with as to be 
familiar both by experience and observation to the 
layman as well as to the professional inquirer. It 
affects the entire system, either in the way of pain 
or of derangement of function. Irritative or sym- 
pathetic fever is less apt to be ushered in by w r ell- 
marked chill than is that which may be called spe- 
cific, as for instance that due to malarious influences. 
Chilliness and wandering pains are, however, often 
met with when this condition is first set up. A posi- 
tive decline in surface-temperature may occur, or 
there may be only a subjective sensation without 
such a fall. 

Very soon, even where the first symptom is chilli- 
ness, the temperature rises over the whole body, the 
skin becomes flushed and dry, the eyes bright, the 
breath hot; all the secretions are checked, the pulse 
is greatly increased in quickness and volume, and 
the breathing is somewhat hurried. More or less 
mental excitement always occurs, and sometimes 
amounts to actual delirium. 

Different persons present these symptoms in vary- 
ing degrees, according to the impressibility of the 
nervous system. Other circumstances, such as the 



FEVER. 99 

nature and severity of the local trouble, and the 
more or less plethoric habit of the individual, also 
influence the general disorder. 

Another fact strongly marked in regard to these 
phenomena, is the change which they undergo at 
different times of the day. This, I need scarcely 
observe, is common to all febrile states, as well as 
to some other morbid conditions. 

A patient with inflammation will be very apt to 
be more feverish in the latter part of the day, and 
at night, than during the forenoon; and if the gen- 
eral symptoms are kept up for several days, or a 
week, or more, this cyclical rotation will hardly fail 
to be noticed. 

There are three channels by which the influence 
of local lesions may be communicated to the system 
at large — the nerves, the blood-vessels, and the lym- 
phatics. 

It is not difficult to see how these channels are 
respectively made available. When the changes 
already mentioned in the nervous element of any 
inflamed part are considered, it is clear that there 
must be as it were a report made to the central 
organs, the brain and spinal cord, of the disturbance. 
Hence a reflex influence will be exerted upon all of 
the peripheral portions of the nervous system. This 
effect will be in direct ratio to two things : the 
severity of the disturbing cause, and the sensitive- 
ness of the entire apparatus. 

In a person, therefore, whose nervous system is 
either naturally or abnormally impressible, a com- 
paratively slight local lesion will induce severe gen- 
eral symptoms. No difference in the degree of these 



100 LECTURES ON INFLAMMATION. 

symptoms will exist between two persons of like sen- 
sitiveness, if the local disturbance be of like gravity 
in each. 

The blood-vessels and the lymphatics may be made 
channels of communication between the affected part 
and the general system in one or more of three ways. 
Either the circulating liquid, the blood or lymph, 
may be changed to an appreciable degree in passing 
through the part, or it may be made the vehicle for 
distributing the products of disease; or the vessels 
themselves may become the seat of inflammation, 
which extends along their walls until it constitutes 
a source of trouble. 

Now in most cases, perhaps in the great majority 
of cases of inflammation, it is the nervous system 
by which the general disturbance is excited. 

And from the facts established by daily experi- 
ence in regard to reflex actions and sensations, the 
mode in which a local disorder may thus disturb the 
whole economy is not difficult to conceive. We can 
just as readily explain how the irritation from an 
inflamed breast is transmitted to the cerebrospinal 
axis, and thence outward again to the heart and 
arteries, as how the tickling of the sole of the foot 
causes a reflex contraction of the muscles of the 
leg. Sometimes, indeed, as has been already men- 
tioned, the reflex influence of an inflammation is 
still more plain, as when one breast is inflamed, and 
the other becomes so secondarily, without any direct 
cause for such a disturbance. 

One point must be noticed here. The amount of 
fever is not always in apparent proportion to the 
severity or extent of the local lesion. Thus a small 



CAUSES OF FEVER. 101 

carbuncle will give rise to very annoying febrile 
symptoms, while an injury involving a much larger 
part may scarcely excite the pulse. But it is evi- 
dent in the first place that the system may be much 
more impressible in one case than in another, and 
secondly, that the character of the local trouble will 
have much to do with that of the general disturbance. 
Kay, it may be that the same systemic state which 
determines the liability to fever determines also the 
occurrence of the local lesion ; such is probably the 
case in the instance just mentioned, of a carbuncle. 
So it would be, too, with poisoned wounds ; although 
here the objection may be raised that we cannot ex- 
clude the influence of a change in the blood-mass 
by the poison introduced. 

But herein lies the very difficulty which besets all 
physiological as well as pathological studies, namely? 
that of separating certain chains of cause and effect 
from those which surround them or are interwoven 
with them. Could we only isolate the nervous sys- 
tem for purposes of experiment, or the vascular, we 
might clear up some very intricate questions. 

It is not, however, merely the pain caused by the 
inflammatory state which gives rise to fever, for we 
have, in that most obscure and ill-defined condition 
known as neuralgia, far more intense pain without 
febrile movement. And here again the confession 
must be made that the difference between these two 
states is not yet known. The facts we have, but no 
satisfactory explanation of them has yet been given. 

As to the effect produced on the system by local 
inflammations, through the blood-vessels, it is evi- 
dent that much depends on the bulk of the affected 



102 LECTURES ON INFLAMMATION. 

part. For example, it cannot be conceived that a 
leg or arm should be extensively inflamed without 
a material influence being exerted upon the blood- 
changes going on in the system. For in such a case 
a large portion of the circulating blood would be in 
relation with the affected part; the transfer of chem- 
ical elements from the blood to the tissues and from 
the tissues to the blood would be, within the affected 
area, altered or interfered with ; and upon the view 
already mentioned, that each part or organ stands 
in the relation of a secretion to all the rest of the 
body, it is manifest that there would be an accumu- 
lation to some extent of certain ingredients in the 
blood, which should normally be removed, and a 
removal from it of others which should normally 
be retained. Perhaps also there might be in some 
cases a new formation, as it were, of unwholesome 
materials in the blood. 

Should the affected organ be one which has a 
special function, such as the liver or spleen, it is 
obvious that these excesses or deficiencies, or de- 
rangements of relation between it and the circula- 
ting blood, will be more marked and more injurious 
than where the function is lower in the scale. 

Should the affected organ have an office directly 
connected with the formation or normal changes 
of the blood, such as the spleen, or the mesenteric 
glands, the trouble induced by its inflammation may 
be readily explained. 

And this disturbance will be more marked in 
cases of single organs, than in such as are double, 
w T here that of one side, if unaffected, can substitute 
that of the other. 



CAUSES OF FEVER. 103 

As to the importance of the lymphatics as a means 
s of communication between inflamed parts and the 
system at large, it is somewhat difficult to speak 
positively, the same obscurity existing here as in 
the case of the blood-vessels. But no doubt can 
exist that the extension of the local disease along 
the lymphatics, or the taking up in the current flow- 
ing in them of morbid materials, are the two modes 
in which they are most frequently the agents of such 
communication. 

With regard to the production of febrile sjonp- 
toms, which is the point now in question, we may 
probably leave the lymphatics out altogether. There 
is no evidence of their taking any part in this in 
ordinary cases, otherwise than as modifying the for- 
mation of the blood so far as they are themselves 
altered locally. It may be that in dissection- wounds, 
for instance, a poison is carried along them, which 
by entering the circulation gains access to the nerve- 
centres and acts as an irritant, so as at least to influ- 
ence the character of the febrile movement. But 
in the fever of ordinary frank inflammations, what- 
ever change may take place in the processes carried 
on by the lymphatics is probably wholly subordinate 
to that occurring in the nerves and blood-vessels. 

To sum up, then, the inflammatory or sympathetic 
fever usually met with is to be ascribed to the irrita- 
tion of the nervous system, manifesting itself by re- 
flex phenomena; in some degree also, when the local 
disorder is extensive, to the disturbance of the regu- 
lar blood-changes of the economy, and in a very 
much less degree to the alteration of the lymphatics 
or their contents. 



104 LECTURES ON INFLAMMATION. 

But the fever, although the inflammation is not 
materially diminished, is generally noticed to sub- , 
side after a few days are past. 

This may be accounted for partly by the tolerance 
acquired by the nerves of the affected part, as well 
as by the cerebro-spinal axis, — partly also by the 
change which so often takes place in the local state, 
when suppuration is established. In most cases there 
is a manifest relief derived from this or any other 
discharge, so far as the heat and pain are concerned; 
and the area of the redness is also much diminished. 

Another circumstance which goes to account for 
the subsidence of the general excitement is the 
tolerance acquired by the nervous centres, so that 
the effect of the local trouble is less felt by them. 

Perhaps also the blood-changes are so equalized 
by the various organs that the condition of the blood 
approaches more nearly to the healthy standard, so 
that whatever influence this liquid, disordered by 
the local disease, may have had in giving rise to the 
fever, is withdrawn either wholly or in part. 

It would therefore appear that the febrile move- 
ment is as it were the effect of a shock upon the 
cerebro-spinal axis, due to a disorder of some part 
of the periphery of the nervous system. This shock 
may be either primarily depressing, excitement oc- 
curring subsequently, or it may act at once as an 
irritant. 



LECTURE IV. 

CAUSES OF INFLAMMATION — THEY MUST OPERATE ON INDIVIDUAL CELLS 

THEY MAY BE MECHANICAL, CHEMICAL OR VITAL — IRRITABILITY 

REFLEX NERVOUS INFLUENCES DIRECT RESPONSE OF CELLS TO STIM- 
ULATION MECHANICAL CAUSES — CHEMICAL VITAL RATIONALE 

LAW OF IRRITABILITY, FUNCTIONAL, NUTRITIVE AND FORMATIYE 

LAW OF REACTION LAW OF MUTUAL RELATION OF PARTS LAW OF 

SYMPATHY SPECIAL APPLICATIONS OF THESE LAWS TENDENCY TO 

ADHERE TO NORMAL TYPE — CONTAGIOUS INFLAMMATIONS INFLU- 
ENCE OF HEAT AND COLD TUBERCLE AND CANCER AS CAUSES OF 

INFLAMMATION. 

Ox the last occasion when I had the honor of 
meeting you, gentlemen, we were occupied with the 
study of the phenomena of inflammation. One of 
the general statements which I made in my first 
lecture, with regard to this disease, was that it was 
essentially a derangement of nutrition; and this led 
me to discuss at some length the rationale of the 
process by which the tissues are normally main- 
tained in life. "We then took up one by one the 
changes in the state of a part, which, when occur- 
ring together, warrant us in saying that such a part 
is inflamed. The character of these changes, and 
the circumstances upon which they are dependent, 
were detailed. The influence of the complex local 
disturbance on the general mass of the blood next 
claimed our attention ; and finally, a sketch was 
given of the constitutional symptoms which make 
up what is so well known under the name of fever. 

10 (105) 



106 LECTURES ON INFLAMMATION. 

Let us now go back of the fully developed state 
of inflammation, and examine into the causes by 
which it is brought about — by what agencies a part, 
duly nourished and regularly fulfilling its function, 
is so disturbed as to become gorged with blood, 
swollen, hot, painful, and incapable for the time of 
continuing its normal office in the economy. 

I have before had occasion to urge the fact of the 
passive obedience of matter to external influences — 
its entire want of any power of spontaneous action. 
This idea is of importance in connection with our 
present subject. Every change must be owing to a 
direct and adequate cause. And in so saying, I do 
not mean merely to make the general statement 
that disease cannot arise spontaneously, but to re- 
duce this to its lowest terms, — to assert that of the 
millions of cells going to make up any part or organ, 
no single one can become deranged without a spe- 
cial and sufficient influence acting upon it to change 
its state. This idea is manifestly parallel to the one 
which was urged in regard to healthy nutrition and 
function, — that each special cell or tissue-element 
has its own nourishment to receive, its own waste 
to repair, its own work to do. 

Let me again bring up my military comparison. 
In a body of soldiers under fire, not one will be 
killed or wounded unless he himself is struck. 
And yet it would be quite as reasonable to account 
for the death or wounding of one soldier by saying 
that he was among a number of others who were 
injured in like manner, as to say that one cell of the 
liver is involved in inflammation merely because 
others are. 






MUTUAL RELATIONS OF CELLS. 107 

Of a dozen men exposed to the contagion of small- 
pox, not one will take it because the rest do, but in 
every case the occurrence of the disease is ample 
evidence that the patient was directly subjected to 
a sufficient influence of the poison. 

There is not between the tissue-elements anything 
analogous to the force of example. The men of a 
regiment may be morally contaminated by the cow- 
ardice of a few; but they cannot, as was before re- 
marked, be physically injured by bullets which do 
not strike them. And in dealing with the cells and 
the intercellular substance we have to do only with 
individuals on a smaller scale. 

Perhaps I ought here to say that I do not mean 
to ignore the influence which the state of one cell 
or other tissue-element may have upon those adja- 
cent to it. Thus it is quite rational to admit that 
the electrical state of one such cell may induce a 
similar state in its next neighbor — and so on until 
a large number perhaps are involved. Perhaps a 
force similar to that known in chemistry as cataly- 
sis — a certain change of state being induced in one 
atom or combination of atoms by the fact that its 
neighbors have undergone or are undergoing a like 
change — may exist between the elements of the 
organism. But in every such case, whatever be the 
influence exerted, it is brought to bear directly upon 
the individual which is the subject of it. And it 
must be remembered, when we speak of electricity 
and catalysis, that they belong to the imponderable 
forces. They have to do only with the relations ob- 
taining between material elements, causing, so far 
as we have yet been able to ascertain, nothing more 



108 LECTURES ON INFLAMMATION. 

than a change in the arrangement of the atoms enter- 
ing, for instance, into a chemical compound. This 
change may indeed be so momentous as to affect 
the affinity between the constituents of the com- 
pound, and thus to break it up ; but this separation 
I take to be incidental only to the main case. 

Given certain atoms in a certain state of combina- 
tion into similar sets, and a change in one set may 
induce a corresponding change in another set; but 
no amount of electrical or catalytic force can induce 
anything more than such a change — can add an 
atom or subtract one. 

In any case, however, my original statement re- 
mains unimpaired, — that no element of any organ- 
ized tissue can be affected, either within the bounds 
of health or in the direction of disease, without a 
sufficient cause acting immediately upon it. 

It will perhaps be noticed, and possibly it might 
by some be objected, that in the views just expressed 
the cells or tissue-elements alone are spoken of; that 
no allusion is made to any influence exerted on the 
vessels or nerves of the part. How far such an in- 
fluence may be regarded as necessary or important 
in the causing of inflammation, we shall presently 
have to inquire more particularly. But I may an- 
ticipate by saying, that the view I shall endeavor to 
uphold will correspond with that advanced in con- 
nection with the subject of normal nutrition and its 
variations, viz.: that it is the tissue-elements whose 
maintenance in life and in the performance of their 
several functions is of paramount importance in 
the economy. Changes which do not affect them 
are of trifling moment. To them the vessels are 



INFLUENCES AFFECTING ORGANS. 109 

passive ministers, the blood a mere pabulum. The 
cutting oft* of their supply of food may cause theii 
death; the gorging of them with an excess of it will 
of itself only hamper their functions. I shall try to 
show that unless a cell is directly influenced by some 
legitimate cause of the inflammatory state, it will 
not enter into that state. In other words, I would 
regard the cell as the agent of healthy life and func- 
tion, and as the true theatre of whatever morbid 
change may take place. 

If now we consider the influences to which the 
physical organization of man is subject, w T e find that 
they may be in general terms stated to be mechan- 
ical, chemical and vital. So far as the mind by its 
changes affects the body, it does so through that 
incomprehensible connection which exists between 
the former and the nervous system. Our observa- 
tion begins outside of this, which we cannot attempt 
to explain. The brain only, as the physical expo- 
nent of the mind, may be directly acted upon by it; 
but this influence is brought about through the con- 
nection just mentioned, and is, so far as it is within 
the sphere of human inquiry, altogether analogous 
to those exerted upon other organs. For instance, 
overexcitement of the mind may induce inflamma- 
tion of the brain ; but all we know about it is, that 
the physical structure of the brain has had an undue 
amount of work demanded of it, or has been abnor- 
mally stimulated, just as the liver or kidney might 
have been, and that the result is a certain morbid 
change in its nutrition. 

Another remark seems to be necessary before 
10* 



110 LECTURES ON INFLAMMATION. 

taking up the consideration of the separate classes 
of causes mentioned as giving rise to inflammation. 
The mechanical and chemical agencies are not in 
strictness distinct from the vital. They are so only 
because up to a certain point they can be followed; 
but they must there be met by the same answering 
susceptibility which every living tissue possesses to 
the changes which occur around it, and without 
which no manifestation of life is possible. It would 
be idle, in the present state of biological science, to 
try to explain this; and it must be a qualification 
merely of our reasoning. 

The influence of mechanical causes in giving rise 
to inflammation is not very difficult to trace ; al- 
though it is often complex in its character. A heavy 
blow, or a gunshot, tearing and bruising the tissues, 
will obviously disturb all that portion of the body 
affected by it, killing or destroying some cells, and 
deranging the balance of others. It cannot be im- 
agined that such an injury should be inflicted on 
living tissues without the neighboring parts suffer- 
ing irritation. And the cells thus irritated have 
but one way of responding to the stimulus — they 
attract more blood. They at once begin to carry 
on a more rapid interchange of chemical substances 
with the blood, to undergo more rapid waste, and 
in some degree a more rapid renewal. Further, 
there is at first, although it may be for so short a 
time as to wholly escape notice, an increase in the 
activity of function of the part. 

I would, if possible, qualify these statements so 
as to make them express more accurately the idea 
of the utter passiveness of the tissue-elements; but 



IRRITABILITY OF TISSUE-ELEMENTS. Ill 

the poverty of our conventional language makes it 
difficult to do so. If sulphuric acid is poured on 
carbonate of lime, it decomposes it, taking hold of 
the lime and driving off the carbonic acid. "We 
speak of the chemical process as going on very ac- 
tively, although we know that the acids and the 
alkali are passively submitting to the circumstances 
under which they are placed, and could no more 
refuse to obey the inexorable law of their affinities 
than a plummet could resist the attraction of gravi- 
tation. 

A man who is irritated can control himself, or he 
can deliberate in what way to wreak his resentment ; 
a dog, less highly endowed, will bite at what annoys 
him; the living tissues neither know nor feel, but 
blindly obey the physical law under which they 
exist. It is partly from their connection with the 
mind or instinct which knows and feels, partly from 
the seeming irritation of the perceptive and respon- 
sive faculty which belongs alone to an immaterial 
principle, that we have been led to apply to their 
passive changes expressions which would seem to 
assign such a faculty to these unwitting atoms. 

Let me remark here that in speaking of the irri- 
tability or irritation of tissue-elements, the idea of 
pain is not at all involved. The susceptibility to 
pain, or to any sensation whatever, is possessed ex- 
clusively by the nervous system. It is unnecessary 
for me to enlarge further on this point, which would 
indeed have been deducible from other statements 
which either have been or will be made in the 
course of our discussion. 

Another element which enters into this irritation 



112 LECTURES ON INFLAMMATION. 

of tissues by mechanical causes, and which compli- 
cates its study, is the effect which cannot but be 
produced upon the nerve-filaments of the part. We 
have already seen that there is abundant proof of 
the influence of the nerves upon nutrition. Now if 
in any way the peripheral portion of the nervous 
system is subjected to local excitement, it is well 
known that there will be an influence transmitted 
along the different nerve-trunks to the spinal cord 
or to the brain, and thence again a response sent 
out, constituting what is known as reflex action. 
And this may or may not be a matter of sensation, 
according to the character and degree of the impres- 
sion, and the state of the brain at the time. For 
instance, if the mind is earnestly engaged upon a 
certain object, absorbed in it, severe injury may be 
sustained without the cognizance of the brain, food 
may be taken without any excitement of the sense 
of taste, and other external impressions pass unno- 
ticed; while very complicated muscular actions may 
be gone through with in an automatic way. It is 
as if the report of a disaster befalling a part of an 
army, or a requisition for supplies, should be re- 
ceived and acted on by a subordinate officer, without 
previous reference to headquarters. 

Now the question next comes up, can this want 
of cognizance include the whole nervous system — 
is it possible for the tissues to act for themselves, to 
respond directly to stimulation, as the soldiers of a 
suddenly attacked force might fire upon their assail- 
ants without waiting for the word of command ? I 
think we must believe that they can do so. 

The idea of such a power is not without analogy 



DIRECT IRRITABILITY. 113 

in the normal state of the tissues. One of the best 
known and most palpable instances of this kind is 
found in muscular fibre, which will contract under 
the influence of stimulants directly applied to it, 
when wholly separated from nerve-structures. Todd 
and Bowman, Carpenter, Dalton, and other authori- 
ties in physiology might be quoted in support of 
this point, did time permit. 

But if such a property exists in muscular fibre, it 
would be hard to show that it could not belong also 
to other structures. Moreover, it does not simplify 
matters at all to assert that all stimuli must take the 
roundabout course of reflex action in order to reach 
the tissues. By so assuming, we add another ele- 
ment to the process, but it is one which is itself 
beyond our comprehension — one which may be de- 
scribed, but cannot be explained. 

Nor does the division of the main nerve supplying 
a part prevent that part from b-ecoming inflamed. I 
do not know what might be the effect of the cutting 
off of all the nervous supply, but certainly there may 
be a very great interference with innervation, with 
an actually increased tendency of the tissues de- 
pendent upon it to pass into the inflammatory state. 
A case illustrative of this will be mentioned in con- 
nection with those causes of inflammation which for 
want of a better term I have classed as vital. 

One other statement, although somewhat prema- 
ture, seems to bear upon the immediate subject of 
discussion. In the case of an incised wound, divid- 
ing nerves and vessels alike, we find that inflamma- 
tion ensues quite as quickly and in as great a degree 
on that edge, which is of necessity cut off from reflex 



114 LECTURES ON INFLAMMATION. 

influence, as on that which is still in relation with 
the central nervous system. 

I think therefore that (always keeping in mind 
the idea that the tissue-elements simply obey pas- 
sively the influences brought to bear upon them, 
and hence that their activity can be regarded only as 
a figure of speech) my assertion holds good, that the 
primary effect of irritation upon them is to increase 
their attraction for the blood, and to promote, al- 
though it may be but for a very short space of time, 
the discharge of their function. 

Subsequently, and just so long as the effects of 
the mechanical injury last, this state of deranged 
nutrition will be kept up. If there is violence done 
•to the tissues so that they need repair, the disturb- 
ance will not be wholly allayed until the repair is 
completed, and the normal condition of things re- 
stored. And let me remind you that in my first 
lecture I took the ground that inflammation was 
always a state of disease. It is therefore set up as 
the result of the injury done, and not as a means of 
repairing it: it is maintained so long and in such a 
degree as the abnormal state which makes repair 
necessary involves irritation. 

The statements now made apply, I think, to every 
form and grade of mechanical violence. It may be 
in some cases, as when a blow is received which is 
just severe enough to induce actual inflammation, 
that the phenomena of this state are developed only 
for a short time, and without any further conse- 
quences — the part soon returning to the condition 
of health. In other cases, as for instance when a 
limb is crushed, or a foreign body forced into the 



CHEMICAL CAUSES. 115 

tissues, the incidental phenomena of suppuration, 
ulceration, adhesion, may ensue; but the essentials 
are the same. 

To sum up then what has been said as to the 
effect of mechanical causes of inflammation ; they 
act directly upon the tissue-elements, irritating them 
and disturbing their nutrition. Whatever agency 
the nerves may exert by reflex irritation is second- 
ary and non-essential, powerful though it may be. 
And according to the statements made in my former 
lectures, this derangement of nutrition accounts for 
the redness, heat, swelling, pain, and disorder of 
function, by which we know the part to be inflamed. 

The study of the chemical causes of inflammation 
need not detain us very long. The living structures 
are made up of atoms subject to the same physical 
laws as if they had not been brought into that mu- 
tual relation which constitutes organization. So far 
as those atoms are concerned, indeed, the bringing 
of them together to make up a cell or a fibre is a 
merely temporary and accidental circumstance. The 
hydrogen and oxygen which are one day, as water, 
associated in the formation of a tissue-element, may 
the next day be either free, or newly combined in 
an inorganic compound. Not a single one of the 
ultimate constituents of the body is in its essential 
nature endowed with life. Upon the cessation of 
this function, the giving up of their charter, if I may 
so speak, the corporation is dissolved, and every 
individual member of it is set free. 

Hence, if for instance a drop of sulphuric acid is 
placed upon the skin, it at once attracts the water 
of that tissue, and thus deprives the cells of an im- 



116 LECTURES ON INFLAMMATION. 

portant compound element in their structure. But 
in so doing it must of course interfere with their 
nutrition, and may carry the interference so far as 
to destroy their life. The neighboring cells are 
likewise affected, but in a less degree; they are 
stimulated, and inflammation is the result. We 
have here also the dead cells acting as mechanical 
irritants, and thus adding to the disturbance. 

Another instance of the production of inflamma- 
tion by a chemical cause is seen when intense heat 
is applied to a living tissue. Not only is the water 
of the part boiled away, but the other constituents 
are wholly changed in their relation; they may be 
all driven off* in vapor, the carbon alone remaining. 
Here then is a foreign body to be gotten rid of, 
while a powerful stimulus, which however belongs 
rather among the vital causes of inflammation, is 
applied to the surrounding textures. 

It will be noticed in each of the instances adduced 
of mechanical and chemical causes of inflammation, 
that these agencies can only become operative in 
this way upon living tissue. ~No amount of violence 
done to a dead body, or to unorganized matter, by 
cutting, scalding, burning, the application of acids, 
will produce anything like inflammation. And the 
same may be said of those structures, such as the 
epidermis or the hair, which, although still in con- 
nection with the living frame, and even performing 
a function, mechanical as it is, are no longer the 
seats of the nutritive process. 

It is only when there is a nutrition to be disor- 
dered, then, that inflammation can occur. 

"We approach now a difficult part of our subject, 



VITAL CAUSES. 117 

— those causes of inflammation which I have called 
vital ; which consist in agencies which affect the 
special conditions of life, apart, so far as can be ob- 
served, from any mechanical or chemical change. 
From the remarks made a moment ago, it may be 
seen why I qualified my original division of the 
causes of inflammation into mechanical, chemical 
and vital. The difference between these agencies 
lies, not in the changes to which they respectively 
give rise, but in the mode in which they do so. 
And hence they are not clearly defined one from 
the other, in their relation to the tissues. A severe 
blow upon the skin, or the application of a drop of 
sulphuric acid, must obviously act in different ways, 
although they bring about the same result; and the 
chilling of the skin which causes a bronchitis is just 
as clearly operative in still another way. In all, liv- 
ing tissue is irritated, and responds to the irritation; 
but in the third instance we have to do with a pecu- 
liar susceptibility, not only of single cells, but of the 
organism as a whole. Those causes of inflammation 
which I would call vital are often such as would be 
totally without effect unless they were brought into 
relation with the living animal; such as, to take but 
one example, the gonorrhoea!, poison. 

It appears, therefore, that while living tissues, 
whose nutrition is going on, are alone susceptible 
of becoming inflamed, this disease may arise either 
from such causes as act also upon inanimate matter, 
mechanical and chemical agencies, or from such as 
are entirely within the sphere of life. JS'ow in the 
consideration of the two former classes of causes, we 
have stood only on the threshold of the real problem. 

11 



118 LECTURES ON INFLAMMATION. 

Gfven, we have said, a mechanical or a chemical 
force, capable of injuring the tissue or of changing 
its composition, by adding or subtracting atoms or 
disturbing the relation of those already combined in 
it, and the cells so acted on resent the interference, 
become irritated, and exhibit the phenomena of in- 
flammation. No w when we take up the vital causes, 
we shall find that they also derange the nutrition of 
the organic elements upon which they act. How 
they do so, and even in some instances in what they 
consist, we do not know. They cannot be analyzed; 
sometimes they cannot even be described. 

As has been seen, the action of the mechanical 
and chemical causes is exerted directly upon the 
tissues which become inflamed by them. In many 
cases, however, the vital causes operate' most ob- 
scurely. Thus, if the small-pox poison be intro- 
duced into the system, we do not know why it 
should crop out at certain points of the surface, or 
at least by what influence those points are determ- 
ined. IsTor, in the case of metastatic abscesses, for 
example, have we any satisfactory knowledge either 
of the general cause inducing them or of the special 
cause by which they appear at some spots and not 
at others. 

There are four laws which are well recognized in 
biology, which have an important bearing on this 
whole subject. One has been already spoken of; it 
is, that in all living tissues there is a susceptibility 
to irritation. According to Virchow T , there are three 
forms of excitement or irritability, — the functional, 
nutritive and formative. Eesulting from the first 
of these there is merely a more rapid discharge of 



LAW OF REACTION. 119 

the duty, whatever it may be, of the elements acted 
upon by the stimulus. From the second, there arises 
a more energetic absorption of nourishment by the 
cells, etc., which already exist, so that they grow. 
Upon the third there ensues a formation of new 
elements, by the enlargement and division of those 
which previously constituted the tissue. Just so 
long as a part, or an organic individual, a cell, is 
being; nourished and discharging; a function con- 
nected with its nutrition, is it liable to any or all 
of these forms of irritation, or rather of response to 
irritation. Muscular tissue, areolar or fibrous tissue, 
gland-cells, may all be shown to undergo them. On 
the other hand, epithelial or epidermis-cells, when 
they have ceased to do more than fulfil a mechan- 
ical and protective office, are no longer capable of 
being irritated. The parts underlying them may be 
so strongly stimulated as to be actually inflamed; 
but the effete cells are wholly unaffected. 

The second of the laws alluded to is that of reac- 
tion. After excitement there follows a state of de- 
pression : and conversely, after depression there fol- 
lows a state of excitement. So familiar is this fact 
that I need hardly dwell upon it now; its importance 
to a knowledge of the origin of inflammation may 
be readily understood. 

The third law is more complex; it is that a cer- 
tain relation subsists between different members of 
the economy, which may be looked upon either as 
a balance or an antagonism. To some degree this 
may be readily understood. Thus, according to 
common experience, when the secretory function 
of the skin is active, as in summer, that of the kid- 



120 LECTURES ON INFLAMMATION. 

neys is less so; when, in winter, the skin is chilled 
and rendered torpid, the balance is maintained by 
the increased flow of urine. The complexity of this 
law lies in its actual working; for we find the appli- 
cation of cold to the skin giving rise sometimes to 
inflammation or irritation of the kidneys, sometimes 
to a like disturbance of the bronchial tubes, some- 
times to congestion or inflammation of the liver. 
Undoubtedly in each of these cases there is some 
intercurrent condition, perhaps several, to which 
the special direction taken by the disorder is owing. 
But even where this might be appreciable to human 
observation, it is apt to be overlooked. 

Still another law, a fourth, may be laid down as 
governing the relations of the different parts of the 
living body. It is the law of sympathy — but its ap- 
plication is less wide than that of either of the fore- 
going. Certain organs, and these are generally 
such as are directly connected with the same or 
with closely allied functions, manifest a tendency 
to assume like states. Thus the womb and the 
breast, the mouth and the stomach, are apt to cor- 
respond in their variations. A striking physiolog- 
ical example of this is found in the consensus of 
nearly all the organs in the change which takes 
place at puberty. At this time, doubtless accord- 
ing to a law impressed upon the organism at its 
first entrance into life, there is a sudden increase of 
nutritive energy, manifested by all the organs, but 
apparently with special reference to the new capa- 
city assumed by the generative system. Should this 
latter element of the change be wanting or inter- 
fered with, the others will be only partially devel- 



LAW OF SYMPATHY. 121 

oped, or perhaps will fail altogether. This complex 
fact we explain by saving that the rest of the sys- 
tem sympathizes with the generative organs in their 
excitement. 

But what is the correct physiological meaning of 
this word sympathy? Are we to suppose that there 
is some mysterious sense residing in the brain, for 
example, by which it becomes aware that the stom- 
ach is disturbed; and that it then proceeds to assume 
a new condition, appropriate under the circum- 
stances? Such an idea would be at variance with 
all the other phenomena of living beings, as well as 
of physics generally. A man cannot sympathize 
with another in trouble, unless he either feels or 
imagines that he is himself liable to the same or to 
like distress; and he obviously cannot be moved to 
pity by sufferings of which he has no knowledge. 

Precisely analogous conditions are essential to 
what we call sympathy between different organs. 
If the derangement of one organ affects another, 
the latter must be capable of the same morbid 
change as that undergone by the former, and there 
must be between the two some channel by which 
impressions are readily transmitted. 

Xow when this sympathetic disturbance occurs, 
it is always of the same character in the two organs. 
TTe do not find that the excitement of one gives rise 
to depression of the other, although in the case of 
the antagonism before spoken of there might at first 
seem to be a relation somewhat of this kind. But 
in such organs as have existing between them a 
sympathy properly so called, the process is one of 

11* 



122 LECTURES ON INFLAMMATION. 

transmission; in some way the change which takes 
place in one is communicated to the other. 

It was remarked, when the subject of the influ- 
ence of local disorders upon the constitution was 
under discussion, that there were three channels by 
which this might be effected — the vascular system, 
the lymphatics, or the nerves. And it was then 
argued that the last named of these channels was 
by far the most important in that particular process. 

Upon very much the same grounds it may be 
asserted that the influence of one organ over an- 
other is communicated by means of the connection 
of both with the cerebro-spinal axis. I have re- 
peated, so often that you may perhaps be almost 
weary of hearing it, that the blood-mass is wholly 
passive, receiving and giving whatever is thrown 
into it or demanded of it. And therefore, even if 
it be granted that the change in the blood passing 
through an inflamed part is the immediate cause of 
disturbance in the sympathizing organ, there must 
be still the susceptibility of the latter to be ac- 
counted for; otherwise, why should not every tissue 
which is in any way in relation with the circulating 
blood feel the influence alike? For the question is 
not now as to a systemic condition such as that of 
fever, but concerns a distinct local change, brought 
about indirectly by a previously existing change of 
similar character in another part. 

We are brought much nearer to the ultimate anal- 
ysis of this matter of sympathy by referring it to the 
nervous system. Here we have in the first place, 
beyond all doubt, the phenomena of reflex action. 
By tickling the sole of the foot we induce such an 



KEFLEX ACTION. 123 

impression upon the lower segment of the spinal 
cord that the muscles of the entire limb contract 
and draw it up. And this takes place even when 
all communication with the brain and upper portion 
of the cord is cut off by disease or injury. 

An instance of reflex action in which the effect 
produced is more palpably, although not more really, 
distributed over a set of efferent nerve-fibres not cor- 
responding to the afferent ones irritated, may be 
found in the bringing on of vomiting by tickling 
the back of the tongue. 

It makes no difference that the exact mode of 
transmission of this agency is unknown ; whether 
it be by a change in the electrical state of the nerves 
involved, or by some special force differing from all 
others in nature, the main fact remains as stated. 

Here then is a property established as residing 
in the nervous system by which the phenomenon 
known as sympathy may be plausibly accounted 
for. Through the medium of the brain or spinal 
cord, and without of necessity any consciousness on 
the part of the patient, the morbid state of one part 
may be reproduced in another. 

To sum up the statements thus far made as to 
the causes of inflammation : Mechanical or chem- 
ical agencies may be exerted directly upon the 
atoms of which living cells are composed, and the 
state of those cells may be changed. The cells 
have, in their corporate capacity as such, the prop- 
erty of responding to or obeying stimuli. After 
being in any way depressed, they react. Between 
certain sets of cells constituting organs, an antago- 
nism exists, so that the depression of one organ 



124 LECTURES ON INFLAMMATION. 

induces excitement or irritation of another. Be- 
tween certain other organs, a sympathy exists, so 
that the influences brought to bear upon one induce 
secondarily a like state in the other. 

Allow me to say here again, that in all the argu- 
ments I have brought before you, I have studiously 
sought to avoid what may be called physiological 
superstition — the setting up of a mystery in the 
shape of a vital force, independent of and opposed 
to the ordinary laws of physics. My endeavor has 
been, to take the facts which pertain to our subject 
just as they are; to explain them as far as the pres- 
ent state of science enables me to do so, and to offer 
nothing except on the basis of actual observation. 

Let us now seek to apply the general statements 
made, to particular cases — to ascertain, as far as may 
be possible, the working of these laws in the produc- 
tion of the inflammatory state. This inquiry em- 
braces all the classes of causes already mentioned. 
It calls for a more minute examination of the influ- 
ence of mechanical and chemical agencies, and for 
the specifying of those which, for want of a better 
term, I have called vital. 

Unless we have gone very far wrong in our rea- 
soning hitherto, we must find the rationale of the 
operation of every cause of inflammation in its dis- 
turbance of the conditions of normal nutrition. 
Either the part to be nourished, the quantity or 
quality of the material supplied for this purpose, 
the arrangements by which this material is brought 
into contact with the tissues, or- the innervation 
which is essential to the consummating of the pro- 
cess, must be impaired or interfered with. 



EFFECTS OF HEAT. 125 

Let us take first one of the commonest causes of 
this morbid state, — the application of heat. Touch 
the skin with a hot iron, and the first effect will be 
to alter the chemical relations of the constituent 
atoms of every cell with which the metal comes in 
contact, or to which it communicates its heat. The 
water is vaporized, the albumen coagulated, the 
nitrogen and some of the hydrogen and oxygen 
associated into ammonia, the other chemical con- 
stituents either set free or brought into new com- 
binations. Only a part of the carbon, and perhaps 
an infinitesimal quantity of lime, silica and iron are 
left. Instead, therefore, of the normal living tissue- 
elements, we have a mass of inorganic material. 

Along with the tissue-elements thus destroyed, 
will perish any nerves and blood-vessels which are 
distributed among them. Now we may place out 
of the account all these dead portions of tissue, as 
they are manifestly incapable of any further life- 
action, or of inflammation — and we have to inquire 
into what takes place in the neighboring and still 
living parts. 

It is evident that the cells lying next to those 
destroyed must feel the influence of the heat in a 
marked degree — the next layer will be affected, but 
less powerfully — and so on outward in a diminish- 
ing ratio, until we come to tissue-elements whose 
health is undisturbed. And the direct effect of this 
heat will be to stimulate the cells, each one in exact 
proportion to the degree in which it is acted upon, 
and to induce a quicker interchange between it 
and the blood, a quicker performance of its func- 
tion, and as a consequence of both these facts a 



126 LECTURES ON INFLAMMATION. 

more rapid waste and renewal of its component 
atoms. 

Probably the degree to which this stimulation is 
carried in those cells which sustain it most severely 
is so excessive as to overwhelm their efforts to re- 
spond to it. I use this figurative expression be- 
cause it seems best to set forth the idea. In its 
capacity as a living being, each cell would obey 
the stimulus impressed upon it by discharging its 
regular duty more energetically; but the conditions 
of its normal performance of function are all inter- 
fered with, either by the excess of that stimulus or 
by the changes attendant upon it, and the result is 
simply an undue attraction of blood by the cell. 

In the successive ranges of tissue-elements be- 
tween this and the region of health, the degree of 
excitement will of course be shaded off in lessening 
grades — so that we come first to parts where the 
state is merely one of congestion, and then find this 
becoming less and less marked till it disappears 
entirely. 

Thus far, no mention has been made of the 
change which must be produced in the nerves of 
the affected part. It would be impossible to sup- 
pose that no such change occurred. Without ques- 
tioning whether it consists in an alteration of the 
electrical state of their component atoms, or in an 
impression made upon them as sensory organs 
merely, we may assert that there is carried along 
them a report, as it were, to the nearest ganglionic 
centre, if not to the cerebrospinal axis itself. And 
upon this there is sent outward a response, so that 
the tissues are further excited by reflex action. 



INFLUENCE OF THE NERVES. 127 

I have before argued that this influence of the 
nervous element is exerted upon the organic cells 
themselves, and not upon the vessels or their con- 
tained blood. It is without doubt, I think, an exag- 
geration of that function which the nerves fulfil in 
the normal process of nutrition — and has to do with 
the relation subsisting between the two main factors 
in. that process. 

So long as the local disturbance continues in any 
degree, just so long and just in that degree will there 
be this reflex influence of the nervous system of the 
part. I may illustrate it by a comparison with the 
muscular sense which keeps the cerebro-spinal axis 
constantly informed of the state of every fibre of the 
voluntary apparatus. Here there need not be any 
cognizance taken by the brain of the report so made. 
In the first access of the disturbing agency there 
may be sensation ; but this gradually diminishes, 
either from the brain or the affected part acquiring 
a tolerance of the irritation — so that in the later 
stages of the disease we find one important element 
of inflammation disappearing, viz.: the pain. But 
even when the pain has thus subsided, there re- 
mains a susceptibility to pain — a tenderness, which 
depends on an abnormal state of the nervous fila- 
ments of the part, and is associated with an irregu- 
larity in the influence exercised by those nerve- 
filaments upon nutrition. 

For the sake of completeness, it must be here 
again mentioned that this reflex action of the nerves 
may not only exhibit itself in the aggravation of the 
effect of the direct causes of the inflammation set 
up, but may be exerted also upon parts situated at 



128 LECTURES ON INFLAMMATION. 

a distance from the original disturbance — so that 
when, for example, one eye is inflamed by the pres- 
ence of a foreign body, by overstimulation in the 
way of work, or by any other cause, its fellow may 
be secondarily brought into the same morbid state 
— and so also with the breast or the ovary. In- 
stances of this kind are much more frequent than 
those of entirely separate organs thus sympathizing 
with one another. 

The explanation now given of the mode of action 
of one cause of inflammation seems to me to cover 
all the essentials of that morbid process: the red- 
ness, the heat, the swelling, and the pain. The in- 
evitable sequence of such a derangement, disorder 
of function, does not need to be again dwelt upon — 
while the effusion of lymph or pus, or both, which 
would be apt to occur in a state of things such as 
that which we have been supposing, I have deferred 
noticing until a later period. 

There is another idea in connection with this ori- 
gin of inflammation, which I offer with some hesi- 
tation, lest it should seem to border upon that phys- 
iological superstition which I have before sought to 
disclaim. It is that there is in the organism an 
intolerance of any departure from its normal ana- 
tomical type. Thus the healthy skin is covered 
with epidermis ; it receives no impressions from 
without except through the medium of this layer 
of organized although effete cells. If now this pro- 
tective investment is in any way removed, or if 
there be a foreign body driven into the substance 
of the skin, it is evident that the proper anatomical 
relations of a portion of that tissue are changed. 



CHANGE OF ANATOMICAL RELATIONS. 129 

And so also in the case of a fracture. The broken 
ends of the bone, themselves altered in their anatom- 
ical relations, are brought in contact with muscular 
and fibrous tissues and with nerve-fibres, which 
should normally be subjected to no ruder pressure 
than that which they exert upon one another. 

In the instance of destructive heat before adduced, 
the living tissue-elements are exposed to direct con- 
tact with the inorganic remains of those which have 
lost their vitality — and in this circumstance seems 
to me to lie an additional source of irritation. 

Every case of mechanical violence or chemical 
destruction of which I can conceive contains this 
change of anatomical relation as an element. And 
it seems to me that this mode of accounting for the 
irritation set up by foreign bodies or by dead por- 
tions of tissue is more philosophical, and more in 
accordance with the established principles of biol- 
ogy, than the one commonly adopted, that the tis- 
sues endeavor to expel the intruding or offensive 
substance. The normal anatomical relations of the 
tissue-elements are abolished ; and this of itself con- 
stitutes an irritation. The applications of this idea 
in the explanation of phenomena which daily come 
under the notice of the surgeon are numerous. 

Thus we find that a clean incised wound, other 
things being equal, heals more readily, and gives rise 
to much less inflammation, than a lacerated or con- 
tused one; because in the former case the disturb- 
ance of the anatomical relations of the tissue-ele- 
ments concerned is less serious. 

Again, of two foreign bodies, one of which is 
smooth, evenly-shaped, and without chemical ac- 

12 



130 LECTURES ON INFLAMMATION. 

tion, and the other is rough, jagged, and corrosive, 
the former will be borne much more quietly than 
the latter. A smooth, rounded leaden ball lodged 
in a tissue produces much less inflammation than a 
twisted and irregular fragment of a copper cap. 

I have been led to offer in a somewhat discursive 
way some considerations which I had meant to bring 
before you in more exact order — but perhaps, to 
some of you at least, it will seem as if this discus- 
sion had been already sufficiently prolix. 

There still remain some causes of inflammation 
to be mentioned, which present greater difficulties 
than those which have hitherto engaged our atten- 
tion. 

Certain constitutional conditions are connected 
with the occurrence of this local state. For exam- 
ple, in strumous subjects we meet with various 
forms of ophthalmia. I say various forms, not be- 
cause the inflammation itself differs except in the 
proportionate prominence of its symptoms, but be- 
cause the disease is excited apparently by varying 
local states, affects sometimes one tissue and some- 
times another, and is thus made to assume what 
would seem on a superficial view to be diverse 
types. 

Thus, in charitable institutions where children 
are collected from among the poorer classes, we 
sometimes see actual epidemics of the disorder 
known as phlyctenular ophthalmia — one or more 
pustules surrounded by an area of inflammation, 
involving the cornea superficially as well as the 
whole thickness of the conjunctiva. In other cases 
the ordinary strumous ophthalmia, with photopho- 



VITAL CAUSES OF INFLAMMATION. 131 

bia and profuse lachrymation, occurs. In other 
cases again, the Meibomian follicles seem to be the 
chief seats of the disease. 

Another constitutional cause of inflammation may 
be found in certain poisons introduced into the sys- 
tem. Thus the poison of small-pox, that of syphilis, 
and of many skin diseases strictly so called, may be 
said to act in this way. Analogous to these cases is 
that of the inflammations so often met with as se- 
quelae of enteric or typhoid fever, and so apt to end 
in suppuration. 

In every one of these instances, however, let it 
not be forgotten that there must be a direct cause 
for the local occurrence of the disease — that every 
effect must have a legitimate parentage. Why 
small-pox pustules, or the vesicles of rupia, should 
occur in certain spots rather than in any others, we 
cannot tell — but that they are not sprinkled by 
mere chance, we may be very certain. 

Gout and rheumatism might be added to the list, 
although I need hardly say that all pathologists are 
not agreed in so placing them. 

But the most striking of all the instances of in- 
flammation due to vital causes is one to which allu- 
sion has already been casually made, viz.: gonor- 
rhoea. Here we find a purely local disease, and one 
which to all appearance is undistinguishable from 
any other inflammation of a mucous membrane, 
transmitted from one person to another by means 
of one of its accidental products. It seems as if the 
evidence could not be set aside that the urethra may 
also become inflamed from simple causes of irrita- 
tion, and that the state so induced cannot be distin- 



132 LECTURES ON INFLAMMATION. 

guished from that brought on by impure sexual 
intercourse. Whether the former can be propa- 
gated by contagion, like the latter, I do not know. 
At any rate, certain it is that pus may be in contact 
with the urethra, as in cases where it is discharged 
along with the urine (having been formed in the 
kidney or bladder), without any inflammation being 
excited — but that which owes its origin to a genuine 
gonorrhoea will, so far as we know, invariably give 
rise to a like condition in the mucous membrane of 
the urethra if applied to it. 

Moreover, it must be noted that of the other mu- 
cous membranes, some are liable to take on a simi- 
lar morbid state if touched by gonorrhoeal pus, as 
for instance the conjunctiva, while others, such as 
the lining membrane of the nose or that of the ali- 
mentary canal, are unaffected by it. Here some 
special and unaccountable property is manifestly 
possessed by certain tissues, in virtue of which they 
always respond to certain irritants in a certain way, 
while others, for want of this property, never do. 

Mention has now been made of the production of 
inflammation by the localizing of certain systemic 
disorders, or by the application of irritants under 
favorable conditions of the constitution, and by the 
contact of substances which have a special and direct 
irritating property. It will be seen that in all these 
cases there is evidently a stimulus brought to bear 
upon the part in which the disease occurs — the dif- 
ference between them lying in the mode of localiza- 
tion or in the peculiar power which resides in the 
substance of irritating certain living tissues. The 
change which ensues in the part so influenced is 



ANTAGONISM OF ORGANS. 133 

simply iii obedience to the law of life, that organ- 
ized matter, subjected to irritation, passes into a 
state which we call excitement, and becomes in- 
flamed. 

Another class of vital causes of inflammation is 
made up of those agencies which are primarily de- 
pressing, and of which the best example may be 
found in cold. The secondary excitement, which 
occurs according to the law that in living bodies 
such a reaction should follow depression, presents 
no features differing from those of excitement di- 
rectly produced. We need not therefore allow it 
to detain us. 

There remains to be considered a very interesting 
and important agency belonging among the vital 
causes of inflammation, to wit, the irritation of one 
organ by means of the depression of another. 

To illustrate this, it will suffice to take one in- 
stance of it, which is for obvious reasons the most 
common, — the production of internal inflammations 
by chilling of the skin. The somewhat complex 
state of things which here occurs I will endeavor to 
set forth in as clear and brief terms as possible. 

The first effect of cold is to depress the tissue- 
elements of the skin, just as moderate degrees of 
heat excite or stimulate them. And this depression 
involves necessarily a lessening of the glandular 
function — the perspiration, as every one knows, is 
checked. But the cold acts also upon the involun- 
tary muscular fibres of the skin, causing them to 
contract, and thus diminishing mechanically the 
amount of blood flowing among the tissue-elements. 
Still further, it influences the nerve-filaments dis- 

12* 



134 LECTURES ON INFLAMMATION. 

tributed through the skin, whether by a change in 
their electrical state or by some more specific mode 
of operation, and throws back upon the ganglionic 
centres, if I may so speak, an amount of nerve force 
which must be distributed elsewhere. How far the 
effect of cold may be to hinder the chemical changes 
which have been before mentioned as inseparable 
from the processes of life, can perhaps hardly be de- 
termined, and it seems to me that this must be but 
a secondary and subordinate matter. 

Hence the immediate effect of cold upon the skin 
is depression of the tissue-elements and of the agents 
of innervation, and diminution of the amount of 
blood used up by the organ, for such we may most 
properly call the skin. 

But one of the functions of the skin is the keep- 
ing down of the temperature of the whole body by 
evaporation from its surface. This is of course in- 
terfered with under the circumstances mentioned, 
and we have a stimulus which must be felt by some 
interior organ or organs. 

In what way it is determined on which of the in- 
ternal structures the brunt of the disturbance shall 
fall, where the innervation, and the repressed blood- 
current, and the heat, which now fail to be disposed 
of in the skin, shall come to their inevitable change 
into other forms of force or of matter, cannot always 
be clearly made out. Perhaps any organ which is 
already in a state of full or somewhat excessive ac- 
tivity may be predisposed to become the seat of 
inflammation. Different persons may perhaps be 
differently constituted in this respect — so that while 
in one the liver would readily pass into an inflamed 



SPECIFIC DISEASES. 135 

condition, in another the lungs or the kidneys would 
be more apt to be so disturbed. Undoubtedly, pre- 
existing disease in any organ, such as tubercle, or 
the effect of former inflammatory changes, would 
make that organ especially liable to the derange- 
ment in question. 

And this suggests to me that I ought to allude to 
the causing of inflammation by those diseases which 
seem more than any other to merit the term specific, 
— tubercle and cancer. It does not seem very diffi- 
cult to understand why there should very naturally 
occur, around either a cancerous or a tuberculous 
deposit, a degree of irritation which may pass into 
actual inflammation. And yet I must confess that 
no reason occurs to my mind why the existence of 
such abnormal growths, even when rapidly increas- 
ing, should excite inflammation, otherwise than by 
a reflex influence through the nerves which are by 
them rendered the seat of pain. The question is 
made more difficult by the fact that in so large a 
proportion of cases, during a great part at least of 
their course, there is no inflammation around the 
deposit. It seems clear however that the same laws 
must apply in this as in the other modes of causa- 
tion which I have called vital, although they are 
less easily traced. 

I am aware that the sketch which I have now 
given of the causes of inflammation and their mode 
of action on the economy is imperfect, and that the 
views which have been advanced are open to criti- 
cism. But my endeavor has been to omit no cardi- 
nal or important element of the subject, which is in 
its; very nature a most difficult one to deal with. A 



136 LECTURES ON INFLAMMATION. 

full discussion of it in all its bearings might readily 
be made to cover all the time allotted to my whole 
course, and would after all be perhaps productive of 
no greater practical advantage than that which has 
been laid before you. 

As to the other point, the soundness of the views 
I have advanced, I can only say that they are those 
which candid study has commended to my own 
mind. Nothing short of demonstration can place 
any statement beyond controversy, and in natural 
science, or at least in the existing state of pathology, 
demonstration is impossible. "Even to the present 
day," says a learned German writer, "it is admitted 
that there is scarcely any department of human 
knowledge in which the number of established 
truths and facts, which no one doubts or attempts 
to shake, is so small, as in medicine."* And such 
being the case, one who would discuss subjects like 
that which has engaged our attention this evening 
without being prepared to have his views questioned 
and criticised, must confine himself to the baldest 
platitudes. 

* (Esterlen, " Medical Logic." 



LECTUEE V. 

TERMINATIONS OF INFLAMMATION — ONLY TWO IN NUMBER — TIS MEDI- 
CATRIX NATURE RATIONALE OF RESOLUTION — GANGRENE DIFFI- 
CULTY IN TRACING ITS RATIONALE PRODUCTS OF INFLAMMATION 

STRICTLY SPEAKING BUT TWO LYMPH AND PUS LYMPH ITS 

SOURCE — CIRCU3ISTANCES INFLUENCING ITS CHARACTER THEORIES 

AS TO THE RATIONALE OF ITS FORMATION. 

"We have now, gentlemen, studied all the essen- 
tial phenomena of a fully developed inflammation, 
and have taken a survey of the causes of this state 
and their mode of action. I propose next to call 
your attention to its terminations, so as to complete 
the natural history of the disease in its simplest and 
typical form. We shall then be prepared to inquire 
into the modifications which it presents, and the 
incidental consequences which attend it in some 
cases. 

By some authors, it is stated that inflammation 
may terminate in various ways. Resolution, metas- 
tasis, delitescence, induration, softening, adhesion, 
ulceration, suppuration, and gangrene, are all men- 
tioned as modes of ending of this disease. Other 
writers, I think more correctly, affirm that there are 
but two — resolution, or subsidence of the abnormal 
phenomena, and the death of the affected tissues. 

Delitescence, or the sudden disappearance of the 
local symptoms, and metastasis, or their transfer to 
some other organ, amount, so far as the affected 

(13T) 



138 LECTURES ON INFLAMMATION. 

part is concerned, to the same thing as resolution, 
which will presently be examined at length. 

Effusion of lymph, induration, softening, adhe- 
sion, ulceration and suppuration, are all mere inci- 
dents of the inflammatory process, which does not 
necessarily cease when they occur, but is on the 
contrary, with regard to some of them at least, 
essential to their continuance. 

The gangrene, mortification, or death of the part, 
must of course put an end to inflammation in it, and 
may therefore be properly considered as one of its 
terminations. 

Hence it seems to me to be simple accuracy, and 
not a hypercritical refinement, to say that there are 
but two modes in which an inflamed tissue or organ 
can cease to be so ; either by the phenomena of that 
morbid state disappearing, and the health of the part 
being in so far restored, or by the death of the part. 
It must be observed that the statement is not that 
the inflammation gives way to a condition of abso- 
lute health, that the tissue concerned becomes en- 
tirely normal, but only that the phenomena of actual 
inflammation subside. 

"We have now to inquire into this process of reso- 
lution. It is obvious in the first place that a reversal 
of the conditions which brought about inflammation 
will cause it to cease — that whatever tends to coun- 
teract irritation, such as the removal of stimulus, of 
the influence of agencies which make the part less 
sensitive to it, will go to restore the normal state of 
affairs. 

A very common but a very erroneous idea is that 
which has been combated in another connection, 



VIS MEDICATMX NATURE. 139 

and which seems to be involved in some degree in 
the term resolution, — that inflammation is a sort of 
entity, a something superadded to and seated in the 
part, and that it melts away like snow in water. 
The change in nutrition which occurred when in- 
flammation was set up is reversed when it subsides. 

If now the phenomena exhibited by an inflamed 
part, the redness, heat, swelling, pain and disordered 
function, with or without the formation of that new 
deposit known as lymph, be considered, and the ex- 
planation be recalled which was given of the way in 
which these symptoms arise, the rationale of resolu- 
tion will not be very hard to define. 

Much has been said in medical writings about the 
vis medicatrix naturce, and about the natural tendency 
of parts to return to health. This idea of nature has 
been very much misapprehended and misused. It 
really means no more than the system of laws under 
which the atoms of which all material things are 
composed act and react upon one another. And as 
I have before urged, these laws are the same, or at 
least in perfect harmony for organized and for inor- 
ganic matter. Only, in organized beings, we have 
a new condition superadded, and if I may so speak 
a new code also. It is much the same as when a 
body of men organize themselves for any purpose. 
They adopt certain rules and regulations, differing 
perhaps from the laws of the community in which 
they live, because their aim is a special one, but not 
clashing with those laws. 

Hence it seems to me that we may positively 
assert that when a part which has been inflamed 
returns to health, when, in other words, an inflam- 



140 LECTURES ON INFLAMMATION. 

mation ends in resolution, it is by as pure an obedi- 
ence to law, and with as little intention on the part 
of the tissues concerned, as when a chemical com- 
pound dissolved in water by heat is let fall again 
on cooling. The substance, whatever it be, has no 
tendency to be precipitated, but the conditions 
under which it was otherwise are done away with. 
Just in the same manner a piece of India-rubber 
contracts after being stretched; not because it de- 
sires to become shorter, but simply because its nor- 
mal state has been disturbed, and the force which 
so disturbed it has ceased to act. 

The expression " assisting Mature" is often used, 
and with a most excellent practical bearing, as indi- 
cating the true function of the physician or surgeon. 
A most admirable work, full of important and valu- 
able doctrines and precepts, has lately been pub- 
lished by Mr. Hilton, the well-known surgeon of 
Guy's Hospital, London. In glancing over it, my 
attention was caught by the following sentences : 

"In fact, nearly all our best-considered operations are 
done for the purpose of making it possible to keep the 
structures at rest, or freeing Nature from the disturbing 
cause which was exhausting her powers, or making her re- 
peated attempts at repair unavailing. The operation does 
not cure ; it only makes recovery possible, where, without 
the aid of the hand or head of the surgeon, Nature would 
have ceased her competition with the results of the injury, 
or succumbed to the exhausting influence of unmitigated 
disease. In aneurism— I think I am not in error when I 
say that aneurism is cured by rest, and not by the surgeon 
— the surgeon takes care to stop the blood or to moderate 
its flow; Nature herself actually cures the disease by rest." 

I feel constrained, correct as I believe the bearing 
of these statements to be, to enter a protest against 



RESOLUTION. 141 

this idea of a gigantic female doctor, to facilitate 
whose treatment is the sole function of human skill 
and experience. Nature has no powers, and does 
not even exist in the sense implied in such expres- 
sions. Their incorrectness would be of less conse- 
quence if it were not that they are apt to lose the 
figurative meaning to which they are alone entitled, 
and being literally interpreted, to color professional 
thought. Moreover, they go far, when thus used, to 
form a basis for the absurdity called popular medicine. 

The true function of the physician or surgeon is 
then to assist in the carrying out, in the body, of the 
laws governing matter in general, and organized 
matter in particular. His is the intelligence to ob- 
serve under what circumstances the Creator has 
ordained that living beings shall find health and 
comfort, and to devise means by which they shall 
be kept in or restored to such a condition. 

Now, let us ask, what does this vis medicatrix na- 
tures amount to in the resolution of inflammation ? 
It is simply the original healthy status of the part, 
the law of its formation and endowment with life, 
interrupted and set aside for a time by some dis- 
turbing force, but to conformity with which the part 
is restored as soon as that disturbing force ceases to 
act. So long as life lasts, the organ can only fulfil 
its appointed type as to chemical and physical struc- 
ture, and in doing this, as I have already urged, it 
yields a blind obedience to surrounding circum- 
stances. That is, its constituent tissue-elements do 
so, and it is merely their aggregate. 

I am at a loss to conceive where the vis medica- 
trix naturae is supposed to reside. It must be, how- 

13 



142 LECTURES ON INFLAMMATION. 

ever, in the individual cells of the tissue, if any- 
where, since by no stretch of fancy can we ascribe 
it to the nerves, or to the vessels, or to the organ 
itself, as for instance in the case of a muscle or a 
gland. But each cell lives for itself, utterly unaf- 
fected, so long as it is itself not involved, by me- 
chanical, chemical, electrical or other changes of 
its neighbors. And to my mind, while nothing is 
easier than to understand this proposition: a living 
cell, if interrupted in its healthy life by any disturb- 
ing agency, and subsequently restored to all the 
conditions necessary to that healthy life, will resume 
it under the same law which governed its first be- 
stowal; nothing is more difficult than to imagine a 
shadowy force which comes forward when disease 
occurs, and acts as a police to restore order. 

To bring down these abstract statements to the 
concrete, let us take the case of an inflammation 
of the skin due to the presence of a foreign body. 
"Withdraw that irritating agent, and health is re- 
stored — not all at once, for the stimulus applied has 
induced a change, and a change in processes which 
are going on, so that it must make itself felt beyond 
the moment of its occurrence. The same thing hap- 
pens if the foreign body is thrown off by suppura- 
tion ; in either case it is gotten rid of, and the irri- 
tation is done away with ; the tissue-elements are 
no longer excited either directly or through the 
reflex influence of their nerves, and the conditions 
of their healthy life are restored. Hence, simply 
because they are no longer placed in abnormal cir- 
cumstances, they begin again to obey the law of 
their being, for they cannot help it. 



RESOLUTION. 143 

Upon precisely similar principles we may explain 
the return to health of a portion of tissue inflamed 
by chemical agents — or by those causes which I 
have called vital. It is not necessary to define the 
poison of small-pox, for instance, but we know that 
after a certain time its irritating influence upon the 
skin subsides. The pustules dry up, and the in- 
flamed area around each one gradually becomes 
paler and more healthy, until all signs of the dis- 
ease except the change of form disappear. Here 
we have a true resolution. 

And I believe that if we were to examine in suc- 
cession all the inflammations to which any part of 
the body is subject, whether with or without the 
occurrence of those incidents which I have men- 
tioned, — ulceration, suppuration, etc., we should And 
that just so far as the exciting cause is done away 
with, the morbid condition passes off*. Just so far, 
in other words, as the circumstances under which a 
part is placed are those which favor its healthy life, 
just so far will it carry on that healthy life. The 
occurrence of suppuration, of adhesion, of the effu- 
sion of lymph, or of any other change in the normal 
structure, must of necessity prevent, so long as it 
exists, the return of absolute health; for tissue- 
elements which are in relation, not with other tis- 
sue-elements, but with pus, are by virtue of that 
very fact in abnormal circumstances, and prevented 
from living a healthy life. But this is only another 
way of saying that they are irritated, or that their 
nutrition is interfered with. 

Now it might occur to some of those who hear 
me, that the tissues sometimes are in contact with 



144 LECTURES ON INFLAMMATION. 

pus, without becoming inflamed; as for example in 
cases where pus is formed in the upper part of the 
vagina, and flows down that canal without even red- 
dening it; or in the instance before mentioned, of 
pus discharged with the urine, without inducing 
cystitis. These cases are rare; but even when they 
do occur, they do not invalidate what I have said. 
For, be it remembered, the pus is here not in abso- 
lute contact with living tissue-elements, but only 
with an epithelial covering whose very office it is 
to protect the structures lying beneath. The cells 
composing that epithelium are no longer, except in 
the deeper layers of it, in process of active nutrition, 
but are effete, and incapable of undergoing inflam- 
mation. 

Let me adduce one other instance, in which reso- 
lution occurs with an apparent continuance of the 
cause of inflammation. It is that of the encysting 
of balls within the substance of the tissues. For 
reasons which it is unnecessary for me to discuss 
now, this happy result was formerly much more 
frequent in gunshot wounds than it is at the present 
day. But the point I wish to urge is, that in these 
cases the mass of lead at first gave rise to irritation 
and inflammation. Lymph, according to laws to be 
hereafter examined, was effused around it. This 
new substance was therefore interposed between the 
foreign body and the neighboring tissue-elements. 
It is a matter of everyday observation that lead is 
but slightly irritating to the living structures, per- 
haps less so than any other inorganic material; the 
lymph would adapt itself exactly to the smooth sur- 
face of the mass, and was developed into a lowly- 



RESOLUTION. 145 

organized and not very sensitive tissue, which out- 
wardly was in relation with the cells of the affected 
part. Here then were circumstances as nearly as 
possible analogous to those of the normal state; and 
as soon as they were established, the irritation ceas- 
ing, the process of nutrition resumed its healthy 
character, and resolution was accomplished. 

The resolution of an inflammation may take place 
very rapidly, or it may not be completed for a very 
long time. It can perhaps hardly be said to be 
entire until even the abnormal irritability which is 
so apt to be left in the part has subsided. This 
may remain even after the swelling has ceased to 
be perceptible, and the heat and pain have passed 
away. Under such circumstances, it will be evident 
that although the part may as a general thing be 
fulfilling its function normally, it will still be readily 
disturbed, and the inflammatory state reproduced. 

I think however that a distinction may be drawn 
between this irritability, and another phenomenon 
which is always seen for a long time in parts which 
have been inflamed, viz.: the readiness with which 
the vessels become turgid upon the occurrence of 
congestion in the neighboring parts. This is merely 
due to the change in relation between the tissues 
and the walls of the vessels. A greatly increased 
afflux of blood having at one time taken place, the 
channels through which it passed were forced open, 
and kept so for a longer or shorter period. At the 
same time the tissues were hindered in their nutrition, 
and perhaps to a certain extent atrophied. Hence, 
when there is a congestion of the tissues around, the 
vessels of the formerly inflamed part yield to the 

13* 



146 LECTURES ON INFLAMMATION. 

pressure of the current entering them, just as they 
had yielded to a like current attracted by the tis- 
sues, and the phenomenon of redness merely is re- 
produced. Such is seen to be the case in persons 
who have lately had varioloid or small-pox, if they 
blush; the redness being much deeper in the spots 
where the eruption was than in other portions of 
the skin. And so also in a healed wound in the 
hand; if the member be allowed to hang down, so 
that the blood gravitates into it, the area of the for- 
mer inflammation will be accurately mapped out by 
the marked redness which occupies it. 

It may be noticed that in either of these cases the 
redness will be deepest at the points where it was so 
originally, and will shade off into the hue of the 
surrounding skin in just the same way — showing, I 
think, that it is due to the change already alluded 
to, viz.: to that of relation between the vessels and 
the neighboring tissue-elements. 

When in the course of time the healing of a 
wound is perfected, and the nutrition of the part 
restored to a state of absolute health, this phenome- 
non is no longer observed; the vessels and the 
tissue-elements have acquired their original rela- 
tion, and are no more affected by changes in the 
blood-current than they were before inflammation 
had taken place. 

Perhaps I need scarcely say that the resolution of 
chronic inflammation is altogether analogous to that 
of the acute. It leaves behind it the same liability 
to congestion, in a more marked degree, indeed, 
because the habit becomes more confirmed; or, to 
speak more correctly, the change of relation be- 



COMPLETENESS OF RESOLUTION. 147 

tween the vessels and the tissues is more persist- 
ently established. 

Along with the return to the healthy condition of 
the part, which is implied in the term resolution, 
there is also, of course, a resumption of the normal 
relation of the tissues concerned to the rest of the 
body. The due interchange of nutriment and effete 
substances begins again between those tissues and 
the blood. And thus, be the extent of the disease 
large or small, whatever secondary disturbance of 
the economy may have ensued upon it is done away 
with. 

The fact must not be overlooked, however, that 
in the course of an inflammation there may be ma- 
terial changes in the part, which remain after the 
immediate phenomena of the disease itself have sub- 
sided. Thus, to take a very familiar instance, a joint 
which has been inflamed is very apt to be stiffened, 
perhaps permanently, by the adhesions which have 
taken place in and around it. Here there may be 
complete resolution of the inflammation, and yet 
the part cannot be said to have regained absolute 
health. In the case of medical inflammations I be- 
lieve we may add that there sometimes is palpable, 
or at least appreciable abnormity of relation to the 
rest of the body even after resolution has occurred, 
as for example in the case of the lung, spleen, or 
liver. 

According to the views now presented, then, the 
disease inflammation terminates by resolution when- 
ever its symptoms subside, leaving nutrition as 
nearly healthy as possible; although the part may 
have become the seat of material changes, the cor- 



148 LECTURES ON INFLAMMATION. 

rection of which requires time, or which may even 
be permanent. 

Before leaving this subject, let me call your atten- 
tion to the fact that in an inflamed part resolution 
and suppuration may take place at one and the 
same time. This, in a case where the area occu- 
pied by the disorder is extensive, may be readily 
observed; it happens, I think, in almost all cases in 
which pus is formed. For when the central por- 
tions of the inflamed part are undergoing suppura- 
tion, the area of redness, swelling and heat becomes 
more limited, simply by the occurrence of resolu- 
tion in its periphery. A very marked example of 
this is found in the case of boils and carbuncles, 
which are apt to be surrounded by a good deal of 
redness and swelling, but which, as soon as the pro- 
cess of suppuration fairly begins, become in appear- 
ance much smaller, owing to the subsidence of the 
phenomena about their outer margins — and this 
subsidence is nothing more or less than resolution. 

The other termination mentioned as possible for 
inflammation was gangrene, or the death of the 
part. It is more difficult of investigation than the 
other and more favorable one, for reasons which 
will readily suggest themselves. Let us however 
try to obtain some light as to the mode of its occur- 
rence. The question before us, then, is, under w r hat 
circumstances do inflamed tissues die ? 

When any portion of the body ceases to live, it 
must obviously be by reason of some interference 
with the essentials of its nutrition. And these 
essentials are, in the higher animals, proper nour- 



CAUSES OF GANGRENE. 149 

ishment, and a due supply of it, a proper state of 
the part, and a certain influence of the nervous sys- 
tem. In other words, the relation between the blood 
and the tissues must be of a certain kind, and sub- 
jected to a certain degree and mode of innervation, 
in order to healthy life. Should either of these con- 
ditions be absolutely wanting, nutrition must fail — 
and death must inevitably ensue. 

Now the causes of inflammation, as I have de- 
scribed them, were either mechanical, chemical or 
vital. 

It is easy to see how by mechanical causes the 
death of a part may be brought about. The crush- 
ing or tearing of tissue which takes place, for in- 
stance, in a railroad injury or a gunshot wound, 
must so change their structure as to render them 
incapable of maintaining their life. 

And so also when chemical agents disturb the 
composition of the cells, by abstracting atoms from 
them or by breaking up the combinations of those 
atoms, the alteration thus produced may be so rad- 
ical and complete as to place the keeping up of the 
processes in which life consists out of the question. 

In both these cases we have in the cause of the 
inflammation a cause also of death to a portion of 
the tissue, as was shown on a former occasion. And 
the same may be said of some of the vital causes of 
the disease — they act as irritants, and they kill cer- 
tain portions of the tissue concerned. 

There are three forms of relation which may exist 
between inflammation and gangrene, as observed in 
practice. I say "may exist," because in some cases 
it is doubtful which of the three obtains. 



150 LECTURES ON INFLAMMATION. 

Thus we may imagine the same cause, not me- 
chanical or chemical, but vital, to induce at once 
the death of a portion of tissue and the inflamma- 
tion of that which surrounds it; so that the two 
states would be simultaneous, parallel, and not in 
order of sequence. 

Or, the starting-point may be the death of a cer- 
tain congeries of cells, which act as foreign bodies, 
or at least no longer maintain their normal ^relation 
with the neighboring tissue-elements ; and hence, as 
has before been explained, the conditions of healthy 
nutrition are interfered with, and inflammation is 
set up. 

Thirdly, there may be so violent an inflammation 
excited in a part, or to speak more accurately there 
may be so wide a departure from health in this direc- 
tion, that the tissues die in consequence of it. 

To take the familiar instance which I have al- 
ready used, it is often difficult to say which of these 
explanations should be given in a case of carbuncle. 
Here we see first an area of inflammation, the cen- 
tral portion of which is evidently deeper and higher 
in degree than the rest. IsTow more blood is pass- 
ing through the tissues which constitute that area 
than they would normally contain. But it is evi- 
dent that this increased amount of nutritive mate- 
rial is not taken advantage of by the part, for after 
a time there is a total failure to live, an actual death, 
at the very point where the greatest amount of that 
material is collected. If all the other conditions 
were maintained in proportion to the augmented 
supply of blood, the tissue, instead of dying, would 
grow. Hence, for some reason or other, the due 



GAXGREXE. 151 

interchange of nutritive and effete substances be- 
tween the blood and the tissue-elements does not 
take place. If we look upon this w T hole process as 
the result of a constitutional disorder, as it no doubt 
often is, it would be in accordance with the patho- 
logical views of many surgeons to ascribe the death 
of the central portion of tissue and the inflammation 
of that surrounding it to the same localized poison. 
Or, we may say, and sometimes with apparent rea- 
son, the course of the disease is, that a portion of 
the subcutaneous areolar tissue dies from such a 
localized poison, and then the surrounding struc- 
tures become inflamed just as they would have 
done if the death or necrosis had been due to me- 
chanical violence. Again, it often seems as if the 
first phenomenon was an intense degree of inflam- 
mation, ending in the death of the central portion 
of the affected tissue, simply as a result. As a gen- 
eral thing, in the choice between these explanations 
the surgeon will be influenced in each case by the 
degree of certainty with which any local cause can 
be designated. If no such cause appear, the view 
will seem plausible that some general poison, local- 
ized in a way which cannot be clearly defined, lies 
at the root of the trouble. 

^Vhat has now been said will suffice to show the 
main difficulty in the way of tracing in any indi- 
vidual case the relation between the inflammation 
of a part and its death. It is not often that an op- 
portunity offers itself of observing a pure and sim- 
ple inflammation which apparently runs on into a 
condition of gangrene. I am inclined to believe 
that such a thing is impossible, on grounds to be 
presently stated. 



152 LECTURES ON INFLAMMATION. 

But, on the view that inflammation is a disorder 
of nutrition, and that this latter process is by it ren- 
dered less active and energetic, we may assume that 
the more violent the former, or in other words the 
wider the departure from the healthy state, the 
greater will be the resulting weakness, and the de- 
fect of nutrition therein involved. Moreover, we 
know that the relations of the several tissue-elements 
of a part which is inflamed to their sources of sup- 
ply are interfered with — and therefore that they are 
not only rendered less able to avail themselves of 
what they have, but the quantity of nourishment 
furnished them is inadequate. 

And we know that the longer this state of things 
lasts, the less capable is it of being corrected. There 
must be a steady and progressive loss of power to 
carry on the life processes, while oxidation is going 
on, and chemical combustion taking place even more 
rapidly than in health. 

Hence it needs but a keeping up of the disorder, 
whether by the continued action of the cause, or by 
its original severity, or by some failure of the powers 
of the system at large, to wear out the part, as it 
were, and thus cause its*death. I do not know that 
any closer analysis of the connection between the 
inflammation of a part and its death can be arrived 
at. But I think that whenever such a result occurs, 
it is owing either to the original cause of the trouble, 
or to some constitutional defect. Perhaps it may be 
said that gangrene never takes place except from 
one or the other of these circumstances — in other 
words, that when inflammation terminates thus, it 
is always through conditions external to itself. A 



GANGREXE. 153 

very rude and imperfect parallel, but one which will 
in some degree illustrate the point, may be found 
in the supposition of a horse compelled to run until 
he falls. He is obliged to do more than his strength 
is equal to. For a time he responds to the stimulus 
of the lash, but at last his powers fail. And be it 
observed, no horse would ever run himself to ex- 
haustion in this way; he can do so only under the 
pressure of stimulation. So it is also with the 
tissues. 

An illustration of this principle may be found in 
muscular contraction. It is not possible for a mus- 
cle to rupture itself, by its own force. When this 
seems to occur, it is by an excessive influence de- 
rived from without. Thus, when the rectus abdom- 
inis is torn across, as has happened in a number of 
instances on record, it is not by its own contraction, 
but by the power of other muscles which are thrown 
into violent action, so as to bring a great strain upon 
it. When other muscles are ruptured, as is some- 
times the case in tetanus, it is because they are in 
a state of excessive spasm from the disease of the 
nervous system. 

And just as it is impossible for simple muscular 
contraction to be a cause of rupture of that tissue, 
so I think it is impossible for any tissue to carry the 
excitement of its nutritive function beyond a certain 
point unless under the influence of some excessive 
stimulus from without, or which is the same thing 
in substance, unless there is a disproportion between 
the degree of stimulus brought to bear upon it and 
the provision made for the repair of its waste. 

I have now discussed the modes of termination of 
14 



154 LECTURES ON INFLAMMATION. 

inflammation which seem to me to be legitimately 
so called; taking the ground that this morbid state 
can come to an end in either one of two ways; first, 
by the subsidence of the symptoms, and so far by 
the return of health, or, secondly, by the loss of life. 
The former event may be due either to the cessation 
of the agency which gives rise to the disease, or to 
its counteraction by artificial means ; the latter either 
to the overwhelming stimulation of the part by the 
cause of the trouble, or to the want of power to carry 
on the processes beyond a certain point. And this 
want of power may be ascribed sometimes to the 
part itself, sometimes to the system at large. 

Before leaving this subject, I think it but right 
to say that there is a certain apparent propriety in 
speaking of ulceration and suppuration as termina- 
tions of inflammation, and indeed I am willing to 
admit that in one limited sense such an expression 
is absolutely correct. For, paradoxical as it may at 
first seem, this does not involve any weakening of 
the position before taken. 

"When a part, as for instance a portion of skin and 
the areolar tissue underlying it, becomes inflamed, 
we have the phenomena so often referred to, — red- 
ness and heat, swelling and pain, with loss of func- 
tion. And eventually a portion of the tissue may 
be broken down into pus, either by the formation 
of an abscess or by ulceration. The exact identity 
of these two processes will be hereafter shown; but 
the point now to be made is, that so far as these 
tissue-elements so disposed of are concerned, the 
inflammation does truly end in suppuration or in 
ulceration. But, granting this, it is no less true 






FORMS OF DEATH. 155 

that those tissue-elements are, as such, dead — and 
hence that their inflammation has resulted in their 
death as parts of the living body. Moreover, it is 
especially clear in such a case as this, that the phe- 
nomena of inflammation do not subside in the neigh- 
boring structures, but persist as long as the forma- 
tion of pus continues, and often much longer. 

I am aware that the same may be said of the 
ordinary process of death or gangrene of an in- 
flamed part, — that in the neighborhood of such a 
part there is still, and must of necessity be, a con- 
tinuance of the disorder. But in one case there is 
what may be called a virtual death only, and so far 
as the whole theatre of the inflammation is con- 
cerned, a subordinate element of that process insti- 
tuted; while in the other there is an actual death, 
and in many cases, if not in most, the inflammation 
w 7 hich remains in the neighborhood begins from 
that moment to decline. 

We have now, gentlemen, completed the study of 
the natural history of inflammation, in the simplest 
form under which it presents itself. We began by 
considering it as it appears when fully developed, 
and examined in succession the various phenomena 
of which it is made up. Next we inquired into the 
causes by which this morbid state is brought about ; 
and finally, we investigated the modes in which it 
terminates. 

There remains still something to be done, in order 
that we may have a full view of the disease ; we must 
look at the products to which it gives rise. It has 
been a matter of much doubt with me, whether it 



156 LECTURES ON INFLAMMATION. 

would not be better, before taking up this subject, 
to examine into the anatomical peculiarities of the 
various tissues; but I believe we shall accomplish 
our purpose more satisfactorily by first turning our 
attention in a general way to the so-called inflam- 
matory exudations. 

You will probably remember that when speaking 
of the causes of the swelling which forms so constant 
an element of inflammation, I stated that it might 
be due to the escape from the blood-vessels either of 
blood as such, or of the watery portions of it, or of 
a liquid closely resembling the liquor sanguinis or 
lymph. And it is a matter of experience as well 
as observation with almost every one, that in very 
many cases of inflammation the swelling is in great 
measure formed, at a somewhat late stage of the 
disorder especially, of the liquid known as pus. 

Of all these exudations, blood, serum, lymph and 
pus, the last two only can be looked upon as prop- 
erly speaking products of the inflammatory process. 
Blood may be effused as a consequence of rupture 
of the vessels under almost any circumstances, and 
may give rise to inflammation, but it does not be- 
long to it as a product, even incidentally. And, as 
in the familiar instance of anasarca, the watery por- 
tions of the blood may be mechanically caused to 
escape through the walls of the vessels, without 
there being any .inflammatory condition in the sys- 
tem at all. 

Hence the present inquiry is narrowed down to 
the formation, in inflamed parts, of lymph and pus. 

Concerning the origin of inflammatory lymph, the 
views of pathologists have varied greatly from time 






INFLAMMATORY LYMPH. 157 

to time. As to its physical characters, they are not 
hard to observe. It is a substance presenting dif- 
ferent degrees of consistence, from that of an almost 
clear liquid to that of a semi-solid. In color it is of 
various shades, from a slightly opalescent, almost 
colorless hue to a decided yellow. Placed under 
the microscope, it exhibits equally diverse charac- 
ters — sometimes it is scarcely distinguishable from 
blood deprived of its red corpuscles, sometimes it is 
quite strongly fib rill atecl. 

A property always more or less marked in this 
substance is its tendency to coagulate — so that it 
early acquired the name of "coagulable lymph. " 
An expression very common among writers on pa- 
thology is the " throwing out of coagulable lymph." 
The correctness of this phrase will be presently 
discussed. 

Now it was said a few moments ago, that this 
lymph was scarcely distinguishable in appearance 
from blood deprived of its red corpuscles. And it 
will of course occur at once that these two liquids 
have another property, that of coagulation, in com- 
mon. It would therefore be very natural to infer 
that they are the same; that in order to the produc- 
tion of lymph, there should be simply an escape 
from the vessels, through their walls, of the liquid 
portion of the blood, with its colorless corpuscles. 
But to this theory there is one very grave objection, 
— that it is impossible for a body like one of the 
colorless corpuscles of the blood to pass through a 
membrane such as constitutes the capillary walls, 
without a solution of continuity in the latter. Some 
other explanation must therefore be sought. 

14* 



158 LECTURES ON INFLAMMATION. 

The view which tallies best with all the facts of 
the case, and the one which accords with the state- 
ments advanced and defended in the course of our 
previous inquiry, is that the development of lymph 
is effected under the direct influence of the tissue- 
elements among which it comes into existence. 
That is, when inflammation occurs, the change in 
the relations between the blood-vessels and their 
contents on the one hand and the cells of the part 
on the other, is such that an escape takes place from 
the former of certain ingredients, which under the 
influence of the latter undergo organization into 
special forms. Besides the general ground of anal- 
ogy, we have in favor of this mode of stating the 
case the fact, which will be further developed here- 
after, of the marked influence exerted upon the 
character of lymph by that of the tissues in con- 
nection with which it is formed. Especially is this 
displayed in those cases in which the organization 
of the inflammatory product is carried on to the 
formation of tissues, as for example when bone is 
developed in the neighborhood of bone. 

Side by side with this truth must be placed an- 
other, viz., that the state of the blood has much to 
do with the further history of the lymph separated 
from it. One of the simplest and best modes of ob- 
taining lymph is by means of blisters applied to the 
skin. Let me quote Mr. Paget's account of a series 
of experiments made by him in the investigation of 
this subject: 

"To test this matter," says he, "I examined carefully the 
materials exuded in blisters, raised by cantharides plasters, 
applied to the skin in thirty patients in St. Bartholomew's 
Hospital. Doubtless, among the results thus obtained, there 






ORIGIN OF LYMPH. 159 

might be some diversities depending on the time and sever- 
ity of the stimulus applied ; still, it seemed a fair test of the 
question in view, and the general result proved it to be so. 
For, although the differences in the general aspects of these 
materials were slight, yet there were great differences in the 
microscopic characters; and these differences so far corre- 
sponded with the nature of the disease, or of the patient's 
general health, that at last I could generally guess accu- 
rately, from an examination of the fluid in the blister, what 
was the general character of the disease with which the 
patient suffered. Thus, in cases of purely local disease, in 
patients otherwise sound, the lymph thus obtained formed 
an almost unmixed coagulum, in which, when the fluid was 
pressed out, the fibrine was firm, elastic, and apparently fila- 
mentous. In cases at the opposite end of the scale, such 
as those of advanced phthisis, a minimum of fibrine was 
concealed by the crowds of corpuscles imbedded in it. Be- 
tween these were numerous intermediate conditions which 
it is not necessary now to particularize. It may suffice to 
say that, after some practice, one might form a fair opinion 
of the degree in which a patient was cachectic, and of the 
degree in which an inflammation in him would tend to the 
adhesive or the suppurative character, by these exudations. 
The highest health is marked by an exudation containing 
the most perfect and unmixed fibrine; the lowest, by the 
formation of the most abundant corpuscles, and their nearest 
approach, even in their early state, to the characters of pus- 
cells. The degrees of deviation from general health are 
marked, either by increasing abundance of the corpuscles, 
their gradual predominance over the fibrine, and their grad- 
ual approach to the characters of pus-cells ; or else, by the 
gradual deterioration of fibrine, in which, from being tough, 
elastic, clear, uniform, and of filamentous appearance or fila- 
mentous structure, it becomes less and less filamentous, softer, 
more paste-like, turbid, nebulous, dotted, and mingled with 
minute oil-molecules. w * 

Mr. Paget goes on to say that so far as observa- 
tion has gone, the analogy or parallelism thus drawn 
between the condition of the system and the quality 

* Lectures on Surgical Pathology, p. 220 (Am. ed., 1854). 



160 LECTURES ON INFLAMMATION. 

of the lymph exuded in blisters holds good also with 
regard to the clots found in the heart after death. 
And this is what would have been expected from 
what we know of the relation between the state of 
the blood and that of the general health. 

Another circumstance, which must materially in- 
fluence the physical characters of the lymph formed 
in any case of inflammation, is the amount of serum 
which, whether by mechanical agencies or other- 
wise, is present along with it. This, as was before 
remarked when the effusion of lymph was incident- 
ally mentioned in connection with the phenomenon 
of swelling, may be looked upon as a mere dilution. 
Obviously, when the quantity of serum is large, the 
solid constituents, the corpuscles and flbrillated ele- 
ments, must be relatively diminished. Such is apt 
to be the case in persons of weakly constitution and 
relaxed tissues. But so long as it exists, it doubt- 
less prevents the permanent organization of the new 
material, as indeed would a priori have been sup- 
posed. 

Hence we have seen that when, in any case of 
inflammation, the so-called effusion takes place, this 
may be either of a liquid corresponding to the serum 
of the blood, — water holding some albumen and cer- 
tain salts in solution; or of a substance nearly anal- 
ogous to the blood itself, but destitute of red corpus- 
cles; or of a mixture of these two. And we notice 
also that in this lymph, whether diluted or not with 
serum (but more markedly the less the quantitj^ of 
serum), there is a tendency to the fibrillation of cer- 
tain of its constituent elements. The circumstances 
determining the character, in any case, of the sub- 






RATIONALE OF PRODUCTION OF LYMPH. 161 

stance effused, are found to be : the state of the 
system at large, acting probably through its influ- 
ence upon the general blood-mass ; the normal 
structure of the part concerned; and the degree, 
as well as the nature, of the disturbing agency. 

In robust persons, and in parts whose tissues are 
compact, the effused material is dense and quickly 
fibrillated; in weakly patients, or in relaxed and 
flabby parts, it is a thin liquid, and tends to remain 
in that state. Of the influence of the anatomical 
structure of the various tissues, I shall have occa- 
sion to speak more particularly hereafter. The 
effect of the degree and nature of the disturbing 
cause upon the character of this substance, is some- 
what difficult to appreciate; but we know that in 
violent inflammations the lymph deposited is more 
apt to be rich in solidifying ingredients; and that 
in eczema, for example, the contrary is the case. 

So far our attention has been directed only to 
matters of actual observation; we have not yet in- 
quired into the rationale of the production of lymph. 
It is concerning this that the views and statements 
of pathologists have varied most widely. The idea 
which has most generally prevailed is that either 
from mere mechanical causes, or by virtue of an un- 
explained power residing in the vessels, there was a 
separation from the blood, a filtering through the 
capillary walls, of portions of that liquid; much as 
wholesale desertion might take place from a mili- 
ary force on their march through an enemy's coun- 
try. And from this very vague idea as a starting- 
point, equally vague explanations have been given 
as to the further fate of the material thus as it were 



162 LECTURES ON INFLAMMATION. 

let loose among the tissue-elements. Coagulable 
lymph, being thrown out, coagulated; just as blood 
drawn from the vessels would do so. 

But any rational theory of this occurrence must 
account in the first place for the passage of the 
atoms of lymph through the capillary walls, and 
secondly for the change which takes place in it 
after it has so escaped. For most certainly the 
colorless corpuscles cannot pass through the walls 
of the vessels, and if they could, the number of the 
corpuscles in any specimen of inflammatory lymph 
is far greater than it should be if they were so 
derived. 

The substance which is formed has been thought 
by most pathologists (or at least such would be the 
inference from the expressions they use) to have a 
certain indwelling power of taking on organization. 
And for this idea there is some foundation, since 
when serous effusion takes place, it merely infiltrates 
the tissues ; when lymph is deposited, it assumes 
definite forms, and may pass into a permanent rela- 
tion with the neighboring structures. It may in- 
deed undergo development into definite structure, 
as when the irritation of a foreign body in contact 
with a bone induces exostosis ; here it is beyond 
question that the source of the newly-formed bone 
is the lymph thrown out by reason of the inflamma- 
tory condition of the original tissue. 

But I think it can hardly need any extended argu- 
ment to show that in any such case the successive 
steps of the process are properly so called. In other 
words, it is not that the formation of bone is an ob- 
ject aimed at from the beginning, — that in order to 



■ 






ORIGIN OF LYMPH. 163 

this a substance is separated from the blood within 
the vessels, which substance takes various prelimin- 
ary degrees, if we may so speak, until it at length 
graduates as bone ; but that, under certain influ- 
ences, brought to bear one after another, the plastic 
material undergoes change after change, blindly and 
passively. 

Upon this view, it is evident, we may also exclude 
as special agents in the process the nerves and the 
vessels of the part. Necessary as these may be to 
its completion, they are so only as in the ordinary 
carrying on of nutrition — the vessels as channels 
through which the material requisite for organiza- 
tion flows to the spot, the nerves as conveying that 
influence, however explained, under which the de- 
velopmental changes go on. 

It remains to be seen whether from the results of 
our past inquiry into the process of normal nutri- 
tion, and into the modifications of it which consti- 
tute inflammation, we can derive anything like a 
satisfactory theory as to the origin and development 
of lymph — and with this subject I hope to deal in 
my next lecture. 



LECTUKE VI. 

ORIGIN OF LYMPH THEORY OF BLASTEMA — SCHWANN'S VIEWS — VIR- 

CHOW'S VIEWS — CELLS ALWAYS DERIVED FROM CELLS — DEVELOP- 
MENT OF NEW CELLS BY DIVISION OF PARENT-CELL ENDOGENOUS 

CELL-GROWTH — LYMPH DERIVED FROM THE CELLS OF EPITHELIUM 
OR OF CONNECTIVE TISSUE — ITS PURPOSE NOT ESSENTIALLY PRO- 
TECTIVE DEVELOPMENT OF LYMPH USUALLY INTO CONNECTIVE 

TISSUE OTHER FORMS HOW INFLUENCED DEVELOPMENT OF 

LYMPH INTO HETEROLOGOUS ELEMENTS — FORMATION OF NEW VES- 
SELS — HUNTER'S VIEW MODERN THEORIES. 

At the conclusion of my last lecture, gentlemen, 
you will remember that I was about to take up the 
subject of the origin and development of inflamma- 
tory lymph, with a view to its satisfactory explana- 
tion, if this were possible. 

And first, of its origin. The various tissues, ac- 
cording to the closeness of their normal relation 
with blood-vessels, receive whatever nutritive mate- 
rial they need, and this may be stated as the main 
or central function of their constituent elements. 
And as I have more than once had occasion to re- 
mark, this life of each cell, strictly so called, is most 
intimately bound up with its duty, the latter flowing 
inevitably from the former. Derange either, and 
the other must be disturbed. Hence, whenever any 
irritation is applied to any living cell, the first effect 
of it is to augment the amount of nourishment taken 
up by that cell, and the activity with which it dis- 
(164) 






FORMATION OF LYMPH. 165 

charges its office. This would be true of any one 
cell, if we could imagine one alone to be so irri- 
tated; but in the actual state of things, a congeries 
of cells must always share in any disturbance of the 
kind. 

And thus, according to the views advanced in the 
previous lectures of this course, more blood is at- 
tracted by the cells so influenced, and the vessels 
become turgid; redness, and an increase in the size 
of the part, result. The interchange of chemical 
elements, — the combustion, involved in nutrition, 
becomes more rapid, and hence there is a rise of tem- 
perature; and pain is caused by this, as well as by 
the pressure upon the nerve-filaments, the intrinsic 
change in them, and in some cases by the original 
cause of all the mischief. And the affected cells 
must cease to discharge their office in the economy 
normally. 

Now if the stimulus is continued, the cells will go 
on attracting blood. But they can take into them- 
selves no more nutritive material. Here then is a 
substance all ready to enter into the composition of 
living cells, supplied according to a demand made 
by the tissues, and supplied in greater quantity than 
they can use for their own growth. 

According to the views entertained from the time 
of the origination of the cell-theory until very re- 
cently, this superabundant material was effused into 
the interstices between the tissue-elements of the 
affected parts, and then received the name of blas- 
tema, from a Greek word signifying to bud or germ- 
inate. Within this formless material there was sup- 

15 



166 LECTURES ON INFLAMMATION. 

posed then to begin a process of aggregation of 
atoms here and there, forming nuclei, which at- 
tracted around them still other atoms, and these 
again others, until the cell-contents and the cell-wall 
were formed around the nucleus as a starting-point. 
Schwann, who may be regarded as having been the 
father of the cell-theory, held this view. He says : 

"The following admits of universal application to the 
formation of cells; there is, in the first instance, a struc- 
tureless substance present, which is sometimes quite fluid, at 
others more or less gelatinous. This substance possesses 
within itself, in a greater or less measure according to its 
chemical qualities and the degree of its vitality, a capacity 
to occasion the production of cells. When this takes place 
the nucleus usually appears to be formed first, and then the 
cell around it. The formation of cells bears the same rela- 
tion to organic nature that crystallization does to inorganic. 
The cell, when once formed, continues to grow by its own 
individual powers, but is at the same time directed by the 
influence of the entire organism, in such manner as the 
design of the whole requires."* 

Some trifling modifications of this theory were 
from time to time suggested, but it was as a gen- 
eral thing accepted in very nearly its original form 
until the recent researches of Virchow, and the pub- 
lication of the doctrines based upon them. Accord- 
ing; to this author there is no such thins; as an exu- 
dation of formless substance, within which cells are 
developed by a sort of instinct; but every cell must 
be legitimately descended from some other pre- 
existing cell. In contrast with the quotation just 
given from Schwann, let me make an extract from 
the "Cellular Pathology": 

* Schwann and Schleiden r s Researches (Syd. Soc.'s Transl.). 



ORIGIN OF LYMPH-CORPUSCLES. 167 

"At the present time, neither fibres, nor globules, nor ele- 
mentary granules, can be looked upon as histological start- 
ing-points. As long as living elements were thought to be 
produced out of substances previously destitute of shape, 
such as formative fluids, or matters {plastic matter, blas- 
tema, cyto-blastema), any one of the above views could of 
course be entertained, but it is in this very particular that 
the revolution which the last few years have brought with 
them has been the most marked. Even in pathology we 
can now go so far as to assume, as a general principle, that 
no development of any kind begins de novo; and conse- 
quently we may reject the theory of equivocal [spontaneous] 
generation as well in the history of the development of in- 
dividual parts as in that of entire organisms. And just 
as we can not admit that a taenia can arise out of saburral 
mucus, or that out of the residue of the decomposition of 
animal or vegetable matter an infusorial animalcule, a fun- 
gus, or an alga, can be formed, — we cannot concede either 
in physiological or pathological histology, that a new cell 
can be built up out of any non-cellular substance. Where 
a cell arises, there a cell must have previously existed, just 
as an animal can spring only from an animal, a plant from 
a plant. In this manner, although there are still parts of 
the body where absolute demonstration has not yet been 
afforded, the principle is nevertheless established, that in 
the whole series of living beings, whether they be entire 
plants or animal organisms, or essential constituents of the 
same, an eternal law of continuous development holds 
good." 

The same doctrine is elsewhere further developed 
by Prof. Virchow in relation to tuberculous and 
typhous deposits, as well as to other pathological 
new- formations. 

Xow when a simple incised wound is received, on 
the linger for example, we presently see a somewhat 
glutinous straw-colored liquid poured out between 
its edges. This liquid, taken off on a glass plate 
and put under the microscope, shows the ordinary 
corpuscles known as lymph-corpuscles, floating in a 



168 LECTURES ON INFLAMMATION. 

clear menstruum like the liquor sanguinis. Whence 
do these bodies come? That they must owe their 
origin directly to the tissue-elements from among 
which the liquid escapes, seems beyond a doubt. 
The learned author just quoted would ascribe them 
to the areolar or connective tissue; he says: 

"We may therefore, with trifling restrictions, substitute 
for the plastic lymph, — the blastema of the earlier writers 
and the exudation of the later, — connective tissue with its 
equivalents as the common stock of germs of the body, and 
directly trace to it, as their general source, the development 
of new- formations." 

There are two modes in which an existing cell 
may be imagined to give rise to the formation of 
new cells, viz.: first by division, just as the cell 
which constitutes the ovum is cleft or subdivided 
into millions of smaller cells, which themselves 
grow, divide, and become the parents of others, 
and so on, as long as the new formation of tissue- 
elements lasts. Secondly, by the development 
within existing cells of others, which by the burst- 
ing of the former, or perhaps by the absorption of 
its wall, are left free to grow and take their place 
as individuals in the economy. 

A diagram will render these two processes clearer 
to those unfamiliar with the subject. (Fig. 1.) At a 
is seen a cell of the typical form; at b it is seen be- 
ginning to be constricted in the middle, the nucleus 
undergoing the same change ; c and d represent the 
further steps of the process, and at e the two result- 
ant cells are seen completed. 

The other method of cell-generation is seen at/, 
carried on further at g, and the mother-cell at A, 






MODES OF CELL-GEXESIS. 



169 



bursting, allows its offspring to escape as a fully- 
formed new cell. 

Fig. 1. 

d e 




According to what we see in the study of mere 
anatomy, whether of healthy or of morbid tissues, 
the former of these methods — that by division — is 
by far the more common of the two. A very strik- 
ing example of it is found in articular cartilage, 
where a dozen or more cells may be seen arranged 
just as they were formed by the cleavage and separa- 

Fiff. 2. 




(From Leidy.) 

tion of the primary cell. (See Fig. 2.) And no doubt 
in epithelium many if not all of the elongated and 

15* 



170 LECTURES ON INFLAMMATION. 

binucleated cells which we see would have gone on 
to division into two or more new cells, had their 
life continued. It is perhaps scarcely necessary for 
me to mention the very frequent occurrence, in 
rapidly-growing cancers, of cells with two or more 
nuclei, and of shapes indicating a tendency to divi- 
sional multiplication. 

As to the other mode of origin, — the formation of 
cells within cells, — it is asserted by authors, Kolliker, 
Leidy and others, that it occurs sometimes in carti- 
lage, and is seen also in the supra-renal capsules and 
in the pituitary body. Paget speaks of it as having 
been observed by him in some cases of cancer. I 
am not so presumptuous as to suggest any doubts 
as to the correctness of statements so authoritative ; 
but I may be allowed to say that it has never hap- 
pened to me to be able to convince myself, in the 
cases where such a process of endogenous cell-forma- 
tion seemed to be going on, that the appearance 
was not due to an optical illusion. 

But this is not a matter which belongs to our 
present inquiry — for it is not probable that any one 
would assert that the cells observed in inflammatory 
lymph were of endogenous formation. The ques- 
tion here lies between the development of cells by 
spontaneous generation in a structureless substance 
poured out from the vessels, and their origin in a 
division or proliferation of the elements of the 
neighboring tissues. Now, as will further appear 
when we come to consider the anatomical relations 
of the tissues to one another, there is no conceiva- 
ble situation in which lymph is found as an inflam- 
matory product, where there is not in pre-existence 



FORMATION OF LYMPH-CORPUSCLES. 171 

either epithelium or connective tissue. And accord- 
ing to the views of some recent histologists, the 
alliance between these two is closer than has been 
generally thought. 

But in epithelium we have elements which are of 
extremely rapid development, and which, moreover, 
are low in the scale of vitality, having almost every- 
where an office in great degree protective. And in 
cases of irritation, of the skin for example, which 
scarcely amount to inflammation, we are familiar 
with the formation of large quantities of epithelium 
in a short space of time. 

In connective tissue we have likewise forms of 
low grade, developed quickly, and, which is a step 
farther, analogous to inflammatory lymph in its 
final state. 

If then there is so little evidence for the idea of a 
spontaneous generation of organic forms in the mat- 
ter derived from the blood passing through an in- 
flamed part, as to warrant its rejection, the view 
which has been hinted at, that those forms owe 
their origin to the division or proliferation of already 
existing connective tissue-cells or epithelial cells, 
seems to possess some claims to favor as a substi- 
tute for it. To my own mind, the arguments for 
the latter theory are, in the present state of the 
subject, conclusive. 

It must however be admitted, I think, that the 
fibrillation which is so familiar as an accompaniment 
of cell-formation in inflammatory lymph is not in 
anyway accounted for in the explanation just given. 
Perhaps this point may be cleared up by further ob- 
servation, and the fact of its being still obscure does 



172 LECTURES ON INFLAMMATION. 

not seem to affect the force of the reasoning applied 
to the rest of the process. At all events, I am not 
at present prepared to offer any additional theory 
in regard to it. 

The formation of inflammatory lymph, then, may 
be considered as the work of the tissues, and this not 
merely in the way of an influence exerted upon a 
substance wholly structureless, but by actual contri- 
bution of material. Our first acquaintance with 
lymph is after the arising of the new elements in it. 
We do not know it in an amorphous state, but we 
do know that if exuded through the capillary walls 
it must be in such a state. Very probably there 
may be such an exudation, constituting perhaps the 
liquid in which the newly formed cells are bathed ; 
and it may not be too bold to suppose that the over- 
plus of nutritive material attracted to the part by 
the irritated cells is thus thrown out into the inter- 
stices, as it were, of the developing tissue-elements. 
But this is manifestly a different thing from the co- 
agulable lymph, poured out and at once assuming a 
process of independent and spontaneous cell-genera- 
tion, which has so long been undoubtedly accepted 
by pathologists. 

Another idea which has been received without 
question by almost all who have theorized on this 
subject, is that of the protective or beneficial pur- 
pose of the effusion of lymph. We are told that 
this substance erects a barrier against the extension 
of disease; that it binds together parts which have 
been accidentally separated, and covers up such as 
would otherwise be rubbed when in an already 
inflamed and tender state. 



EFFECTS OF LYMPH INCIDENTAL. 173 

But this rule must work both ways; and if it be 
a beneficent provision of nature that lymph should 
be effused in one place so as to do good, it must on 
the other hand be either a malicious contrivance or 
a careless mistake that a like effusion elsewhere 
should do so much harm, as by the closing of a duct, 
or the stiffening of a tendon in its sheath. 

The truth is, that in either case the effect is in- 
cidental. It is a part of the disease inflammation, 
just as the protection from smallpox which follows 
vaccinia is a part of that disease. It so happens in 
one instance that the lymph organized serves a use- 
ful purpose; but in another it so happens that it 
does a good deal of harm. Perhaps it may be as- 
serted that there is no such thing known to physical 
science as unmitigated evil. 

And here we may consider the relation of the 
effusion of lymph to the repair of injuries. The 
best discussion of this subject with which I am ac- 
quainted may be found in Paget's " Surgical Pa- 
thology." By this author it is clearly shown that 
injuries may be completely repaired without the 
formation of lymph at all — although this occurs in 
most cases. Perhaps nearly every one has met with 
instances of this immediate union. Some years ago 
it happened to me in my own person much to my 
surprise. I cut my finger quite severely with a 
sharp knife; and being busily engaged, I merely 
wrapped a handkerchief firmly about the part for 
some hours; upon removing it the cut was com- 
pletely and permanently closed. Another and still 
more striking instance, I think, was exhibited to the 
College of Physicians during the past year by Dr. 



174 LECTURES ON INFLAMMATION. 

Hewson. It was a specimen from a case in which 
he performed Pirogoff 's amputation, sawing off the 
lower end of the tibia and the anterior part of the os 
calcis, and bringing the two surfaces of bone into 
apposition. They are now perfectly united, without 
any sign of intermediate substance. 

From these cases and similar ones it can only be 
inferred that the effusion of lymph is not essential 
to the healing of injuries. Generally this occurs; 
not as a means of repair, but as a mere incidental 
result of inflammation. And this is the only point 
I wish to urge in regard to it at present. We find 
that after injuries, inflammation takes place, with a 
formation of lymph; and we find that in very many 
cases of inflammation not preceded by any definable 
injury, but apparently arising spontaneously, the 
same deposit occurs. We find, moreover, that in 
one case of inflammation, as for instance in the 
pleura, the lymph serves a useful purpose, as in 
limiting the extent of the disease; while in another, 
as in the urethra, in gonorrhoea, it gives rise to in- 
tense suffering, by binding down tissues which 
should be distensible when the organ becomes tur- 
gid with blood. 

Putting all these facts together, it seems clear 
that the true light in which this deposition of lymph 
should be regarded is as a result of the formative 
irritation exerted upon the tissues of the part. It 
is one of the processes which the Creator has or- 
dained to take place under certain circumstances, 
just as he has established the law of gravitation, or 
the laws under which water freezes. And just as in 
these two cases, it is according to outside conditions 



FURTHER DEVELOPMENT OF LYMPH. 175 

in every instance whether the working of the law 
shall seem to be beneficial or not. In general, it is 
true, all the laws governing matter tend to the ad- 
vantage of living beings; but none of them invari- 
ably do so. 

"We have further to consider the development of 
the lymph originated by the tissues of inflamed parts. 

In the great majority of cases, the form ultimately 
assumed by the adventitious deposit is that of con- 
nective tissue. Sometimes, however, the process 
goes further, and new developments of structures 
allied' to this substance take place. The subject 
opened up by these statements is one of great extent 
and importance, involving several as yet obscure 
points in pathology. I do not feel qualified to do 
more at present than to indicate its scope and 
bearings. 

Allusion has already been made to the cellular 
character of the ovum, and to the mode in which, 
by its division and subdivision, vast numbers of 
cells are generated. From this starting-point pro- 
ceeds the development of all the various tissues 
which enter into the organism. 

In the course of this development connective tis- 
sue, as is well known, occupies an important place 
as a transition-form through which several other tis- 
sues pass before they reach their permanent condi- 
tion. Thus there is a time when the masses which 
are ultimately to constitute muscles, voluntary or 
involuntary, present no difference from connective 
tissue; and out of the same or similar masses all the 
flat bones are formed. 

Xow when we consider the development of in- 



176 LECTURES ON INFLAMMATION. 

flammatory lymph, the antecedent conditions are 
obviously very different from those in the case just 
mentioned. There must be in the latter a certain 
forecast programme according to which every por- 
tion of the organism arises; in the former there is 
simply an accidental production, abnormal in all its 
relations, and determined as to its issue by circum- 
stances outside of itself. Hence in the case of the 
inflammatory deposit, we never know what to pre- 
dict as to its ultimate form ; sometimes it is connec- 
tive tissue merely, sometimes bone, sometimes a 
heterologous or cancerous substance. 

Mr. Paget quotes Mr. Adams as describing, in 
his work on " Chronic Rheumatic Arthritis," the 
supposed development of lymph into articular carti- 
lage; he also says that Virchow u has twice seen 
nerve-fibres in adhesions. In one case, two fine 
nerve-fibres passed through an adhesion of the 
pleura; in the other, a single fibre extended into, 
but not through, an adhesion between the liver and 
diaphragm." 

Forster, in his " Handbuch der Pathologie," speaks 
as follows of these cases : 

"This author (Virchow) observed the presence of nerve- 
fibres in adhesions ; in one case (a pleuritic adhesion) two, 
running close together, had the characters of the finest 
double-contoured nerve-fibres ; in the other (an adhesion 
between the diaphragm and the liver) a single nerve-fibre 
passed along with the connective tissue, divided, and ended 
in a point. Both adhesions were at least \^ n long and 
ribbon-like. 

"It is very evident to me, that these nerve-fibres were 
not of new formation, but should be looked upon as branches 
of the normal nerves of the serous membrane, which were 
carried along with the growing fibrous mass." 



DEVELOPMENTS OF LYMPH. 177 

Mr. Paget inclines to think that lymph may be 
developed into epithelium. He speaks of it as 
covering the surfaces of well-formed adhesions; 
and then says : 

44 1 know of no observations proving whether the epithe- 
lial cells are developed directly from the lymph, or are a 
later construction from materials derived from the blood of 
the adhesion's vessels ; but it is not rare to find, in inflam- 
mation of serous membranes, recent lymph cells presenting 
many characters indicative of development towards epithe- 
lium; flattened and enlarged, and having circular or oval 
clear nucleoli." 

"With the one exception of the nerve-fibres said to 
have been seen by that experienced and accurate 
observer Virchow, it would appear that the tissues 
into which inflammatory lymph becomes trans- 
formed are all mechanical in function and low in 
the scale of organization. Connective and elastic 
tissue, cartilage, bone, epithelium, — all these are of 
this description. In regard to epithelium it must 
be remembered that the recent researches of physi- 
ological anatomists have tended to place it in a 
much closer histological relation with the obviously 
mechanical tissues, and especially with the connec- 
tive, than was formerly supposed. Is"or is this idea 
rendered improbable by the function which epithe- 
lium very generally fulfils, in the way of protection 
to underlying structures. 

As to the mode in which the development of 
lymph is influenced by the already existing tissues 
in its neighborhood, I have nothing to offer. To say 
that it is by a catalytic force, inducing the cells 
simply to imitate those near which it finds itself, is 
only to put the fact in another form, and not to ex- 

16 



178 LECTURES ON INFLAMMATION. 

plain it. Moreover, we sometimes meet with cases 
in which even this condition is wanting, as for ex- 
ample when bony or bone-like deposits take place in 
the subserous tissue of the pulmonary pleura, in the 
muscular structure of the heart-walls, or in the dura 
mater. 

It should be noted that in every instance this de- 
velopment is confined to the production of simple 
tissues; it never goes as far as the forming of organs. 
We cannot imagine such a thing as the construction 
of a supplementary gland, of a supernumerary finger, 
or of a muscle, in this way. I have quoted Paget 
as describing the construction of epithelium, or a 
very good substitute for it, upon the surface of cica- 
trices, as well as upon that of the masses of lymph 
which so often form adhesions between the opposed 
layers of serous linings of cavities. But, in the first 
place, it was also stated that the recent researches 
of German histologists have tended to establish a 
much more intimate relation between the cells of 
epithelium and those of connective tissue than was 
formerly allowed; and secondly, in every such in- 
stance of the formation of an epithelial covering 
there is traceable a direct contact between the outer- 
most margin of the lymph-elements so transformed 
and the previously existing epithelial cells normally 
lining the cavity. 

We have therefore a twofold explanation of the 
mode in which such a transformation may take 
place. It may either be due simply to the accident 
of situation, the connective tissue cells on the sur- 
face of the cicatrix or of the organizing adhesion 
assuming secondarily the shape and function of epi- 



EPITHELIUM FORMED FROM LYMPH. 



179 



tlielial cells, and not needing to undergo, in so 
doing, anything like what might be called a radical 
change. Or, just as inflammatory lymph in the 
neighborhood of bone may acquire the characters 
of osseous tissue, the moulding influence of the 
adjacent epithelium all around the borders of the 
new deposit may be so exerted as to induce the 
cells of that deposit, first at its edges and afterwards 
by successive steps all over its surface, to assume a 
like type. 

The diagram (Fig. 3) will further illustrate these 
views. C is a section of a mass of lymph formed 
between the two layers of an inflamed serous mem- 
brane. At &, 6, 6, b are seen the epithelial cells 
lining the cavity, by the proliferation of which cells 
the connective -tissue corpuscles constituting the 
lymph are formed. At d are seen the superficial 

Fig. 3. 




cells of the adventitious mass, undergoing from the 
accident of their position a change into the epithe- 



180 LECTURES ON INFLAMMATION. 

lial character. At e, e are seen the normal epithelial 
cells advancing so as to form a covering for the 
adhesion -band, the process being still unaccom- 
plished at /. The subserous connective tissue is 
represented at a, a. 

It must be evident that these two agencies may 
be at work at the same time, and therefore that the 
adoption of one does not exclude the other. I do 
not know that in the present state of our knowledge 
we can reasonably reject either, although the mode 
in which an existing tissue influences the character 
assumed by that which is developed in its neighbor- 
hood is so obscure that the whole process may be 
actually open to some doubt from that circumstance 
alone. 

A more serious question, although perhaps not 
one of greater practical importance, is in regard to 
the development of lymph into heterologous or can- 
cerous tissue. Almost invariably, when in any case 
of malignant disease there is an injury spoken of as 
the starting-point of the trouble, it was sustained 
many years before the latter occurred. Thus in a 
case of mammary cancer which came under my 
notice within the last week, the patient remembers 
having sustained a blow at the same point, long 
ago, from the elbow of a person crowding past her 
in the market. Now although a malignant tumor 
may undoubtedly form in many instances without 
such a history being traceable, yet there are so 
many cases bearing the other way that the idea of 
a causal connection seems scarcely to be set aside. 

It may be objected, however, that after a mere 
blow it would hardly be probable that any appre- 



HETEROLOGOUS DEVELOPMENTS OF LYMPH. 181 

ciable quantity of lymph would be deposited, to lurk 
until some accident, or the law of its organization 
called it to act the part of a disturber. The answer 
to this is twofold. In the first place we do not 
know what amount of lymph there may have been 
as the result of the primary injury, and particularly 
in such a region as that of the female breast. Sec- 
ondly, the case has been already quoted of a man 
who had sustained a heavy fall upon the buttocks, 
just before the manifestation of smallpox in his 
person; and the eruption came out far more copi- 
ously there than elsewhere. If we assume the exist- 
ence of a vice of constitution as the primary condi- 
tion of the cancerous disease, then a blow or other 
injury of any part may be readily imagined as pro- 
ducing just the amount of impairment of structure 
which should render that part liable to become the 
seat of a local outcropping of the general disorder. 

Thus far, in the study of the development of 
lymph, I have called your attention only to the 
changes in the structure of the individual tissue- 
elements of which it is composed, these being so 
altered as to assume characters nearly or altogether 
allied to those of connective tissue, of bone, of epi- 
thelium, or perhaps of nerve-fibres. And if it be 
proved in any case that lymph deposited in conse- 
quence of inflammation is so changed as to become 
the basis of a cancerous or malignant growth, this 
is also, so far as the local disease is concerned, a 
development of that lymph. 

But it is by no means uncommon to observe, as 
for instance when a mass of inflammatory lymph is 

16* 



182 



LECTUKES ON INFLAMMATION. 



torn off from a serous surface, that vessels are rup- 
tured in so doing; small red points appearing on 
each of the separated portions. Here is a new feat- 
ure in the subject; the lymph as thus organized in 
connection with the surface is vascular, and our in- 
quiry would be incomplete if we left this fact unac- 
counted for. 

Hunter's idea was, that the formation of the ves- 
sels and their contained blood in the substance of 
organizing lymph was effected in the same way as 
in the embryo — that, of the mass of material poured 
out or exuded from the neighboring vessels, part 
became fibro-cellular, while another part took upon 
itself the form of blood, still another inclosing this 




blood and acting towards it as the vascular walls do 
to the blood within them in the normal tissues. 
This view may be readily understood from the 



FORMATION OF BLOOD-VESSELS IN LYMPH. 183 

annexed diagram. (Fig. 4.) The mass of lymph de- 
posited between two serous surfaces is seen (jB) with 
ramifying vessels (c) forming in its central part. A A 
is the serous membrane, a a its vessels. We must 
either suppose that some cells of those which go to 
make up this mass of lymph assume the characters 
of blood-cells, while others agree as it were to arrange 
themselves into the containing vessels, or else that 
the first-named cells are simply contained in cavities 
which form between the other cells, which preserve 
their primal state. Under what influence those 
blood-cells are developed, how the containing ves- 
sels or cavities are originated, does not appear. 

And yet there ought to be some such rationale 
offered, to justify the assumption that this process 
occurs. The circumstances, be it remembered, are 
not analogous to those of the ovum, where the new 
being is undergoing its development, — but the lymph 
is an accidental and abnormal product. 'No propel- 
ling organ is ever formed, the vessels developed are 
never anything more than capillaries, passive chan- 
nels along which the current flows with a force and 
rapidity determined by causes wholly outside of it. 
No one has ever seen, either within a serous cavity, 
or on the surface of the skin or a mucous membrane, 
a mass of lymph having an independent system of 
blood-vessels in its central portion, while its periph- 
ery was destitute of such supply. And yet, were 
such a phenomenon possible, it could hardly fail to 
be observed, in the abundance of cases likely to 
present it. 

The more modern view is that the vessels border- 



184 



LECTURES ON INFLAMMATION. 



ing on the lymph send out processes into it, which 
gradually advance more and more into it, ramify 
and form anastomoses, and thus establish a capillary 




circulation. The diagram (Fig. 5) will show what 
is meant; the letters being the same as in Fig. 4, 
except that c is a vessel shooting out into the mass 
of lymph, while d is a loop formed at a more ad- 
vanced stage of the vascularization on the other 
side. 

Now the theory I would present is merely a modi- 
fication of this. Rejecting the idea that the vessels 
can of themselves send out prolongations or pro- 
cesses, I would suggest that the newly formed cells 
need blood, and attract it; and that it is the at- 
traction thus exerted, drawing the blood-corpuscles 
toward the cells, which causes the pouching out of 
the capillary walls. These walls, thus yielding, may 



VASCULARIZATION OF LYMPH. 185 

be fairly supposed to become thinner in so doing. 
Very possibly they soon give way altogether, and 
the blood finds a passage in the interstices between 
the lymph-corpuscles. 

The great difficulties inseparable from the study 
of this subject, and the impossibility of demonstra- 
ting the steps of the process, make it especially 
needful to avoid hasty or positive conclusions. The 
theory which I have sketched seems to me to agree 
best with the facts of the case, and perhaps covers 
the whole ground; but I am by no means prepared 
to insist upon it. It will be further discussed in my 
next lecture. 



LECTUKE VII. 

MODE OF DEVELOPMENT OF NEW VESSELS IN INFLAMMATORY LYMPH — 
OF LYMPHATICS, ETC. OFFICE OF LYMPH IN THE REPAIR OF IN- 
JURIES ATROPHY OF LYMPH PUS — PHYSICAL AND CHEMICAL CHAR- 
ACTERS MICROSCOPICAL APPEARANCES MOVEMENTS OBSERVED IN 

PUS-CORPUSCLES ORIGIN OF PUS — VIEWS OF DIFFERENT AUTHORS 

MODERN VIEW. 

You will probably remember, gentlemen, that at 
the close of my last lecture I was engaged in the 
discussion of the subject of the development of in- 
flammatory lymph. We had inquired into the dif- 
ferent changes through which the cells of that pro- 
duct passed before they reached that state which 
was to be retained by them as portions of the 
economy, and had begun to examine into the modes 
in which the blood-vessels and their contained blood, 
which are so often found in the adventitious tissues 
resulting from inflammation, were brought into 
such relations. I use this expression, " brought into 
such relations," designedly. For at my last lecture 
I argued, in accordance with the principles laid 
down in previous lectures, that there could be no 
spontaneous generation of blood and vessels in a 
mass of effused and organizing lymph; and that 
there could just as little be a voluntary pouching 
out of neighboring blood-vessels into such a mass. 
It would not be possible, I think, to demonstrate 
either occurrence ; but nothing short of demonstra- 
(186) 



VASCULARIZATION OF LYMPH. 187 

tion could establish the fact of a process so wonderful 
and improbable as either of these things would be. 

But the fact remains, that we find in adhesions 
formed out of inflammatory lymph, capillary chan- 
nels through which blood flowed during life. And 
these channels, and the blood they contain, must 
have been produced by outgrowth, — not, observe, 
by spontaneous outgrowth, — from the already exist- 
ing vessels of the adjoining tissues. 

The question then presents itself, how does this 
outgrowth take place? You will not be surprised, 
after the views already laid before you, if I deny 
that it is by virtue of any power except such as re- 
ticles in the elements for whose benefit the out- 
growth is to be effected. Here, indeed, it seems to 
me that we have the only clue to the correct expla- 
nation of the process. 

The mass of new tissue-elements, then, which 
constitutes organizing lymph, and the mode of 
whose origin has been so lately the subject of our 
inquiry, needs nutritive material, in fulfilment of 
one of the essential conditions of the life-process. 
And if a sufficiency of nourishment can be obtained 
by imbibition, as by articular cartilage for example, 
there will be no development of new blood-vessels. 

But if the demand is too great to be thus com- 
plied with, it must be felt more at certain portions 
of the extent of each vessel skirting the theatre of 
the new deposit than at others. And at every such 
point there will be of course a greater attractive 
force exerted upon the blood-current passing along 
the vessels than there will be elsewhere. But, as I 
have before urged, the capillaries are mere tubes, 



188 LECTURES ON INFLAMMATION. 

yielding to pressure either from within or from 
without; and if, at every such point, the blood is 
attracted, there must be a tendency in the blood to 
obey the attraction, and to push before it the yield- 
ing membrane of the capillary wall. Hence we 
shall have, at every such point, a pouching outward 
of the vessel. 

Perhaps it may not be too great a refinement to 
assume, that in being so pouched out the wall of the 
vessel loses in thickness; for according to this view 
it does not, at first at least, grow, but is stretched. 
And being thus thinned, the wall of the pouch be- 
comes more ready to give than it was before, besides 
which its shape is such as to offer less resistance than* 
when it was that of a simple tube. It only remains 
for two such pouches to yield towards one another, 
and to give way, to establish a vascular loop; and 
the whole of what seems to me to be the true theory 
of the vascularization of lymph is before you. 

In the same way I would account for the develop- 
ment of lymphatic vessels in these new formations. 
The minute injections of Prof. Van der Kolk, which 
prove the existence of such vessels, have never, so 
far as I know, been suspected of inaccuracy. They 
deal only with adhesions between the costal and 
pulmonary pleurae, when the lymphatic system is 
abundant and exceedingly active, and where, there- 
fore, such a development would be more likely to 
take place than in most other parts of the economy. 

Very little is known of the physiology of the lym- 
phatics, in comparison with that of the other great 
systems ; and hence we can only argue from analogy 



NEW FORMATION OF NERVE-FIBRES. 189 

in regard to the point now in question. Let me 
simply say that it would be entirely gratuitous to 
assume here a power of spontaneous outgrowth 
which is not held to exist in the blood-vessels ; and 
that it would be still more unreasonable to suppose 
that newly organized lymph, if unable to generate 
its own vascular system, could originate what in the 
perfect economy seems to be a mere dependent or 
accessory to the former. 

Again, the arguments against the idea of an 
independent formation of vessels and blood with- 
in effused and organizing lymph would obviously 
apply w 7 ith even greater force against that of such a 
formation of nerve-fibres. Nor is there any reason 
whatever to suppose that neighboring nerves have 
of themselves any more power to send out processes 
into newly deposited lymph than into fully-formed 
articular cartilage. And as the instances observed 
by Virchow stand alone, among the countless cases 
in which no such nerve-formation has been discov- 
ered or suspected, it seems as if we might well con- 
tent ourselves w T ith accepting the fact as stated by 
him, and waiting for further opportunities of study- 
ing the phenomenon. 

Lymph, then, is a substance separated from the 
blood of an inflamed part by the agency of the irri- 
tated tissues of that part, and is probably due to a 
proliferation or a division of the existing tissue- 
elements. It may assume the condition of ordinary 
connective or areolar tissue, and in the great ma- 
jority of cases this is its ultimate state. Or it may 
be further developed into bone, epithelium, cartilage, 
or, possibly, even into nerve-fibres. Generally, how- 

11 



190 LECTURES ON INFLAMMATION. 

ever, the forms assumed are those of the merely 
mechanical structures; even when epithelium is 
formed, it is not fully endowed, for there is no evi- 
dence of its playing its usual part in secretion. 

I would call your attention to the fact that in this 
statement, as in those which preceded it, there is 
neither expressed nor implied the idea that in the 
original constitution of inflammatory lymph there 
is any incapacity to undergo the highest degree of 
development. But the outside influences to which 
the adventitious substance is exposed are not such 
as to induce such a process — and hence, merely for 
want of favoring circumstances, the development 
undergone by lymph is never above a certain grade. 
My own belief is that in any mass of inflammatory 
lymph there is the same capacity for the formation 
of brain-tissue that there is in the cells to which the 
segmentation of the ovum gives rise; but in the one 
case the collateral conditions necessary are wanting, 
while in the other case they are present. 

The position, then, of the lymph which results 
from inflammation, may be indicated in very few 
words. It becomes a living tissue, and may go on, 
under the influence of circumstances, to the as- 
sumption of further and perhaps higher characters. 
Should those circumstances be present, this develop- 
ment must occur in implicit obedience to them; if 
they are absent, it cannot occur by virtue of any 
inherent tendency in the effused substance. 

I think we can now reason intelligently as to the 
office of lymph in the repair of injuries. Its presence 
in such cases is not due to a provision made with a 
view to the healing, but is simply a result of the in- 



REPARATIVE OFFICE OF LYMPH. 191 

flammation which is excited in the neighboring tex- 
tures. But being present, and becoming a living 
tissue, it undergoes development in relation with 
the injured parts, so as to constitute bone in cases 
of fracture, connective tissue, etc. in lesions of other 
structures. Prof. Virchow, in his "Handbuch der 
Specielle Pathologie und Therapie," says: "An 
ossification which appears very useful as a uniting 
callus between the two parts of a broken bone, may 
constitute an actual exostosis if it occurs in a stump 
after amputation." (Yol. i. p. 333.) Instances are, 
as is well known to most of you, constantly occur- 
ring in which outgrowths of bone result from in- 
flammation. I have lately seen two very striking 
examples of the kind ; in one the contact of a ball 
lodged close to the femur had given rise to a number 
of small knobby exostoses on that bone, while in 
the other an extensive necrosis of the femur after 
amputation caused inflammation of the entire stump, 
with conversion of a large mass of the effused lymph 
into osseous tissue. (Perhaps it should be stated 
that no microscopic examination of the structure 
was made, but the extreme hardness and the other 
gross characters presented by it could scarcely be 
mistaken.) 

And in view of the fact that inflammation cannot 
but take place, and generally is plainly observable 
after fractures, it seems to me to be much more rea- 
sonable to ascribe the origin of the lymph which 
becomes the uniting medium to this, rather than to 
the influence of some obscure and newly developed 
sanative agency. Such a theory accords with what 
appears everywhere else in nature, — the accom- 



192 LECTURES ON INFLAMMATION. 

plishment of various ends by the operation of simple 
laws. 

Upon the principles now laid down, it will be 
easy to see that the tissues thus developed by the 
organization of inflammatory lymph must be amen- 
able to all the laws, and affected by all the influ- 
ences, to which the rest of the economy is subject. 
These tissues have a nutrition, which may be dis- 
turbed in different ways. It may undergo the same 
changes, by irritation, as any other portion of the 
economy — so that an adhesion itself due to inflam- 
mation, may in its turn become inflamed. It may 
be impaired, and atrophy result. Any defect in the 
nutrition of the entire system will be especially felt 
by it; and herein may be found the explanation of 
those cases in which the united ends of a broken 
bone are separated afresh, or old w^ounds reopened, 
in persons who become the subjects of syphilis or 
scurvy. 

In such a case of atrophy, there may be not merely 
a loss of consistence, but an actual absorption and 
disappearance, of the material which was the bond 
of union. How can this be explained? Obviously 
it is a very different thing from that lessening of 
bulk which takes place in a part which has been the 
seat of lymphization, to use Prof. Gross's term, and 
which is probably due to the change of condition of 
the new elements, as they become condensed from 
juicy and succulent cells into regular fibrous or con- 
nective tissue. 

One of two explanations must apply to this disap- 
pearance of the adventitious material. Either the 
elements composing it must be broken down struc- 



DEGENERATIONS OF LYMPH. 193 

turally and chemically, so as to become capable of 
solution or actually dissolved, in order to pass 
through the capillary walls into the blood-current, 
or they must be thrown off by ulceration; in the 
latter case a process of breaking down will also 
occur, probably identical or nearly so with that 
which takes place in the former. Neither of these 
modes of disappearance can be practically studied, 
but on general principles we may assume the state- 
ments just made to be correct. 

Mr. Paget has given a brief but excellent exposi- 
tion of this subject in the admirable Lectures which 
I have already quoted so often. Besides the mere 
wasting, probably by absorption, of the lymph 
formed in inflamed parts, he mentions calcareous 
and pigmentary degenerations as apt to be observed 
in it. The apparently bony deposits in the pleura 
or pericardium, before alluded to, may be adduced 
in illustration of the former; the latter is generally 
met with near places where pigment is normally 
deposited, as for instance in the pulmonary pleura 
in the neighborhood of the bronchial glands. 

I think, gentlemen, that the views which have 
now been presented to you with reference to the 
origin and development of inflammatory lymph are 
altogether in accordance with those laid down in 
regard to the healthy process of nutrition. My en- 
deavor has been to follow as closely as possible the 
natural course of the subject, so as to avoid side- 
issues, and to keep hold of the clue which, begin- 
ning in the normal, should guide us to the true con- 
ception of the relation between it and the abnormal. 

It yet remains for us to study the other substance 
17* 



194 LECTURES ON INFLAMMATION. 

which was mentioned as a product of inflammation, 
— pus. For, let me remind you, I took the ground 
that there were properly speaking but two such pro- 
ducts, viz.: lymph and pus. And I remarked upon 
the fact that of all the phenomena which belong to 
this disease, no one alone except the presence of one 
or the other of these two substances constituted 
positive evidence of it. Perhaps this statement 
ought to be somewhat qualified, as regards lymph, 
which is I think occasionally met with where it can 
hardly be supposed that the parts could have been 
actually inflamed, without much more trouble in 
the economy than has been experienced. Thus 
about the base of the brain there are sometimes 
seen irregular masses deposited, presenting all the 
characters of lymph, although the clinical history of 
the case may not afford any evidence whatever of 
an inflammatory origin for them. 

Still, as a general rule, where deposits of this kind 
are found, they may be regarded as results of in- 
flammation; and such is invariably the case with 
pus. And without anticipating, it may be said here 
that while we have seen that the formation of lymph 
tends to the increase of solid constituents in the or- 
ganism, we shall find on the contrary that the for- 
mation of pus is altogether degenerative. So far as 
inflammation is concerned, it is in either case an 
affair of interference with nutrition ; in either case 
the normal process of nutrition is impaired. But 
the formation of lymph is manifestly nearer to the 
maintenance of life and structure, than that of pus. 

The physical characters of ordinary pus are very 
familiar to you; its yellow color, its cream} 7 con- 



pus. 195 

sistence, its greasy feel, its sweetish taste, as well as 
the peculiar odor which belongs to it when in quan- 
tity, and which it leaves on the hands of those who 
have much to do with surgical cases. Such are the 
qualities of what has received the name of healthy or 
laudable pus. Different specimens of it vary, how- 
ever, in several of these points — in some cases it is 
much more fluid than in others, while its yellow 
color may present a more or a less decided greenish 
tinge. 

]N"ow on the ground taken in my first lecture, that 
inflammation was always, wherever met with, a dis- 
ease, you will perceive that it cannot be regarded as 
strictly correct to speak of healthy pus. And yet, 
adopting as a standard that form of this product 
which is observed to occur in healing wounds or in 
simple abscesses, and which corresponds with the 
description before given, it is evident that there is 
a certain propriety in calling that which comes up 
to this standard normal. Such pus is innocuous; 
and therefore differs from the contagion-bearing pus 
of gonorrhoea, or from the pus of an ulcerated can- 
cer. Compared with such products, what is called 
healthy or laudable pus seems fully to merit such 
epithets. Let it be understood, however, that this 
mode of expression is not strictly, but only relatively 
correct; that the presence of pus is infallible evi- 
dence of a departure from absolute health in the 
organ or tissue from which it is derived. Outside 
entirely of the programme of healthy life, lymph 
and pus have for themselves a natural history, which 
may be in various degrees adhered to or departed 
from. 



196 LECTURES ON INFLAMMATION. 

In some cases, especially in what are called chronic 
or cold abscesses, the pus differs very widely from 
the description just given — being mainly composed 
of a thin watery or serous liquid, with curdy flakes 
floating in it. 

Very often pus is streaked with blood, and some- 
times it is intimately mixed up with it, as in the 
rusty sputa of pneumonia. And in cases of ill-con- 
ditioned sores, the local formation of pus being de- 
ficient, and the blood-mass at large being impov- 
erished, we find the discharge to consist of a thin, 
reddish, irritating liquid, which has received the 
name of sanies. Whenever the unctuous feel and 
thick consistence of pus are diminished, it loses also 
its bland character, and becomes acrid, so as some- 
times to scald and excoriate the skin or mucous 
membrane over which it chances to flow. Probably 
in such cases the liquid exchanges its usual chemical 
reaction, which is nearly neutral, for an acid one. 

According to Simon, the specific gravity of pus 
taken from the human subject varies from 1027 to 
1040. He quotes from Gobel the analysis of pus 
from the uterus of a mare, the specific gravity of 
which was 1079. 

As to the chemical composition of pus, the results 
obtained by different observers are, as might be ex- 
pected, somewhat at variance. Water, fatty matters 
and cholesterine, albumen, salts of lime, soda and 
iron with carbonic, sulphuric and phosphoric acids, 
chlorides of sodium and potassium, are the chief 
ingredients detected. Some of these are present 
only in very small amount. The main inference to 
be drawn from the results of these analyses is that 



MICROSCOPICAL CHARACTERS OF PUS. 197 

pus is the product of the breaking down of the 
structures normally composing the economy. 

When pus taken from a simple abscess, or from a 
healing ulcer, is put under the microscope, it is at 
once seen to consist of certain solid constituents, 
floating in a liquid menstruum ; and thus to resemble 
the blood. Some of the early observers, indeed, 
thought that it was nothing more or less than altered 
blood; but this idea has long since been abandoned. 

Mingled with the elements strictly belonging to 
pus, are often found fragments of the degenerated 
or broken-down tissues; epithelial cells, shreds of 
connective tissue, and oil-drops, are the most familiar 
of these forms. Often, especially when the pus has 
been retained for a length of time in the cavity of 
an abscess, its own solid constituents are in process 
of breaking up, and exist only as crumbled fragments. 

The pus-cell, however, when perfect, is a spherical 
nucleated cell, bearing a good deal of resemblance 
to the colorless corpuscle of the blood. According 
to Wedl, there are marked variations in size in 
the pus-cell. "It is as yet undetermined,' , says he, 
"whether these diversities of size are connected with 
the individual by whom the pus is afforded, or with 
the nature of the disease, as J. Vogel supposes, who 
has remarked that the size of the pus-corpuscles of 
an abscess and of a wound is tolerably constant — in 
the one case they are all small, and in the other all 
large."* 

The number of nuclei contained in these elements 



* Pathological Histology, p. 295. (Syd. Soc.'s Translation.) 



198 LECTURES ON INFLAMMATION. 

varies from one to five — the number most generally 
seen, however, is three. These nuclei are strongly 
brought out, as in other cells, by the application of 
acetic acid; each one contains a bright nucleolus. 

Very commonly, perhaps almost always, pus-cells 
contain a greater or less quantity of minute oil-drops ; 
a fact which may be looked upon as connected with 
the degenerative character of the product. 

In the Brit, and For. Med.-Chir. Review for Oct. 
1864, I find a quotation of some singular observa- 
tions reported by Dr. Yon Recklinghausen in regard 
to certain changes of form in the pus-corpuscle. 
This writer claims to have seen in the cornea of the 
frog, infiltrated with pus, and in the aqueous humor, 
a shooting out of processes from the side of the pus- 
corpuscle ; and by the movement of the mass of the 
original corpuscle towards the end of one of these 
processes, the corpuscle itself seemed to change its 
place. He says that "in the fresh condition of the 
human pus-corpuscle there is, besides the change of 
form, also a very lively molecular movement in the 
interior of the cells distinguishable, which movement 
becomes more active at those points where the pro- 
cesses protrude from the 0611." Active changes of 
form were seen by him also, it is said, in the pus- 
corpuscles of a dog and of a rabbit ; and he thinks 
that "the pus and mucus-corpuscles of vertebrata, at 
least during a certain period of their lives, possess 
contractile qualities, which are attested by the change 
of form and the so-called molecular movement. ,, 

In the Arch. Gen. tie Med. for Nov. 1864, I find 
also the following statements : 






MOVEMENTS OF PUS-CORPUSCLES. 199 

"A medical student recently presented himself to M. Sza- 
badfoldy, having upon the glans penis two small pustules, 
which had existed only a few hours, and which there was 
strong reason to believe were syphilitic. The pustules were 
surrounded by an areola of vivid injection ; their contents 
seemed transparent, and they itched violently. The author 
evacuated one of them by puncturing it with a fine-pointed 
needle, and placed the fluid which escaped under a magni- 
fying power of 300-350 diameters. He found it composed, 
in about one-third of its contents, of cells, some rounded, 
some furnished with prolongations. These latter changed 
their form under the eye of the observer ; from being rounded 
they became ovoid, and their appendages appeared and dis- 
appeared by turns. In some they were so numerous as to 
give the cell the appearance of being ciliated, as for instance 
when five or even eight prolongations existed on one face of a 
cell. Some of the cells were elongated, and are compared 
by the author to fusiform cancer elements. Beside these 
were others which recalled completely the large cells with 
numerous appendices met with in some cancerous tumors. 
It was in these cells that the most remarkable changes of 
form were observed ; besides, the contents of many of the 
ceils presented a very elegant molecular movement. 

"The movements observed in these various elements be- 
came slower at the end of 3 or 4 minutes. The addition of 
a drop of acetic acid caused them to cease altogether, while 
all the prolongations vanished. The author subsequently 
examined the drop of liquid which remained in the pustule, 
but found only pus globules in it. The liquid taken from 
the other pustule showed contents analogous to those of that 
obtained from the first, but the characters were less marked. 

" Xo treatment was instituted, and a clearly chancrous 
sore succeeded to the pustules. The liquid from it showed 
no unusual characters. 

" The author has had but one opportunity of making an 
observation of this kind, on the pus from a chancre seated 
in the urethra. (Archiv fur Pathol. Anat, t. xxix., liv. 3 
and 4, 1864.)" 

I can only mention these statements to you, with- 
out expressing any opinion as to their reliability, or 
their value in pathology. So far as my knowledge 



200 LECTURES ON INFLAMMATION. 

goes, they stand alone; and no opportunity has oc- 
curred to me of testing their accuracy by repeating 
the observations upon which they assume to be 
founded. It would seem somewhat strange, how- 
ever, if such changes of form, and such movements, 
were now for the first time noticed, notwithstanding 
the great attention that has been paid to the study 
of pus-cells by so many intelligent and laborious 
pathologists. And perhaps, even if it were placed 
beyond a doubt that such changes did take place, 
they would prove to be simply the accidental effect 
of endosmotic currents through the cell-wall. 

Another solid element sometimes observed in 
pus, and described by most authors as particularly 
constant in pneumonia, is what was at one time 
known as the exudation-corpuscle. It is a spherical 
body, consisting apparently of a mere aggregation 
of granules; in size it exceeds the pus-corpuscle, but 
it is much less abundant. No satisfactory theory 
has been offered as to its origin or nature. I have 
seen this element in pus from the horse. 

Wedl says that while some pus-corpuscles, and 
particularly the larger forms, exhibit a cell-mem- 
brane, they seem in most cases to be bounded 
simply by a delicate granular material. . Upon what 
grounds this statement is based, does not appear 
from his description. Vogel also speaks of a nu- 
cleus surrounded by an indefinite, granular, amor- 
phous precipitate, without a clear outer circumfer- 
ence, and as its behavior in relation to endosmosis 
shows, without a cell-wall. His statement is much 
less general than that of Wedl. It certainly would 
be, however, a strange thing if without any differ- 



ORIGIN OF PUS-CELLS. 201 

ence in origin or purpose, and without any other 
structural variation, so striking a difference should 
exist between two sets of cells. It seems to me 
more correct to say merely that the cell-wafi is more 
plainly developed the larger the corpuscle itself is. 

l^sow according to all the analogies afforded by 
histology, whether physiological or pathological, the 
multiplicity of the nuclei of pus-cells is simply an 
index of the process of division which those cells 
are undergoing. This division would seem to be 
the mode of multiplication of the cells, and its 
almost constant occurrence agrees well with the ex- 
treme rapidity of formation of pus so often observed. 

"We find, then, as one of the products of inflam- 
mation, a liquid containing in it certain cells, and 
these cells exhibiting evidences of rapid multiplica- 
tion in the breaking up of their nuclei. We have 
ample negative evidence that these cells are inca- 
pable of further development, but that they are 
either wholly discharged from the economy, dried up 
into inert masses, or disintegrated and reabsorbed. 

Two main questions arise in regard to these cells. 
The first is, how are they formed? The second, 
what is their relation to the normal elements of the 
organism ? As will be seen, these questions are not 
wholly distinct one from the other. 

Precisely as in the case of lymph, the origin of 
pus-cells may be explained in either of two ways. 
They may arise out of a homogeneous liquid exuded 
from the vessels, by a process somewhat similar to 
that of precipitation or crystallization, or they may 
be legitimately descended from elements already 
existing. There have indeed been authors who en- 

18 



202 LECTURES ON INFLAMMATION. 

tertained the idea that the pus- corpuscle was merely 
a blood-corpuscle which had undergone change. 
Gendrin even went so far as to describe with appar- 
ent accuracy the nature of the progressive changes 
between the two forms. But this idea, although I 
believe it had at one time the support of Donne's 
authority also, has now been long since abandoned. 
The only wonder is that it should ever have been 
endorsed by men of so high reputation as observers. 
One author, Mandl, actually applies the term 
precipitation to the process; his description of it 
does not differ from that of Vogel, which is as 
follows : 

" The process of the formation of pus from a fluid cyto- 
blastema can be best observed in fresh wounds cleansed 
from blood. In examining the fluid secretion from a wound, 
we first observe minute granules, less than the 1000th of a 
line in diameter, which are chemically identical with the 
molecules insoluble in the alkalies and in solutions of borax. 
There then appear, partly around these molecules and partly 
independent of them, somewhat larger corpuscles, soluble 
in the alkalies, but not in acetic acid, identical with the 
nuclei of the pus-corpuscles. These nuclei appear some- 
times isolated, sometimes in groups of twos or threes, thus 
forming composite nuclei; around these the cell-wall is 
subsequently developed, first appearing as a pale trans- 
parent membrane, and subsequently becoming thickened 
and granular; and thus the pus-corpuscle is formed." 

The entire analogy which obtains between this 
description and that before quoted from Schwann 
in reference to cell-formations in general is at once 
evident. It corresponds also with the views held 
by most other writers on the subject. For instance 
Hassall, in his elaborate work on the Microscopic 
Anatomy of the Human Body, maintains that the 



FORMATION OF THE PUS-CORPUSCLE, 203 

pus-corpuscle is an undeveloped epithelial cell; and 
in describing the mode of formation of epithelium, 
he gives a rationale identical with that just quoted 
from Vogel. ITassall, however, differs from all 
other authors w T ith whom I am acquainted, in that 
he thinks that the pus-corpuscles may be developed 
into a protecting epithelium; an opinion which does 
not seem to rest on any adequate foundation. 

Donn£, in his elaborate work on Microscopy,* 
takes the ground that the formation of pus is a true 
secretion. He says : 

" Thus I do not admit that the globules of pus are formed 
at the expense of the fibrin of the blood — that they can be 
considered as a sort of precipitate of the fibrinous part of 
the liquid blood; and notwithstanding their analogy in 
structure and composition with the colorless blood-cor- 
puscles, I do not admit that they have anything in common 
in their origin or intimate nature with these latter. I re- 
gard the pus-globules as a product of special and direct secre- 
tion of the suppurating part, of the pyogenic membrane. n 

In further support of this view, he quotes the 
authority of Berard, one of the contributors to the 
Dictionnaire de Medecine. After all, however, it 
does not seem to me that this does anything toward 
the clearing up of the question. It makes very little 
difference w T hether we call the process of formation 
of the pus-corpuscle a secretion, a precipitation, or 
by any other one word, so long as we do not describe 
it with accuracy. The first thing to be done is to 
ascertain how the forms met with are produced, and 
then the term to be applied to their mode of origin 
may be arrived at without much difficulty. 

* Cours de Miccoscopie, p. 191. (Paris, 1844.) 



204 LECTURES ON INFLAMMATION. 

Nor does it throw much light upon the process of 
suppuration to say, with Hassall, that the pus-cor- 
puscles are simply young or undeveloped epithelial- 
cells, unless we are prepared to show how the latter 
acquire their organization. 

A much more rational view, because one which 
goes deeper into the philosophy of the matter, is 
that taken by Paget. This is that pus is the result 
almost always of the degeneration of lymph; the 
exceptions being those surface-suppurations noticed 
in the conjunctiva and urethra, when there seems to 
be exuded upon an unbroken surface a liquid, which 
is first recognizable in the character of pus. Of the 
former occurrence there are instances continually 
presenting themselves, as in almost every abscess. 
Paget's description of it is so excellent, that I can- 
not forbear quoting it. 

"The change," says he, "almost always begins at or near 
the centre of the lymph, where, we may believe, the condi- 
tions of nutrition are most impaired. It may extend from 
a single point, or from many which subsequently coalesce. 
In either case, the central collection of matter remains sur- 
rounded by a border or wall of indurated tissue, in which 
the infiltrated lymph is not transformed into pus, but rather 
tends to be more highly organized. This border or periph- 
eral layer of lymph now forms the wall, as it is called, of 
the abscess, and the finger may detect, as the best sign of 
abscess, a soft or fluctuating swelling with a firm or hard 
border. The expressions commonly used are, that the sup- 
purative inflammation has taken place in the centre of the 
swelling, and that its effects are bounded by the adhesive 
inflammation; it might be said with the same meaning, but 
perhaps more clearly, that of a certain quantity of lymph 
deposited in the original area of the inflammation, the cen- 
tral portions have degenerated into pus, and the peripheral 
have been maintained or more highly developed; and prob- 
ably we may add in explanation, the difference has depended 



THEORIES OF FORMATION OF PUS. 205 

on the degrees in which the conditions of nutrition have 
been interfered with in the places in which the two portions 
have been seated. In the central parts of an inflammatory 
swelling, the circulation, if not wholly arrested, must be less 
free than in the peripheral ; the blood, moving very slowly, 
or stagnant, must lose more of its fitness for nutrition ; the 
tissues themselves are more remote from the means of main- 
tenance by imbibition ; in these parts, therefore, degenera- 
tion, if not death, ensues, while in the peripheral parts main- 
tenance, or even development, is in progress."* 

I think it must be evident from the recounting of 
these various theories, that there has been a con- 
stant progress towards a satisfactory theory of the 
formation of pus. First there was the one, which 
would naturally suggest itself when the pus-corpuscle 
was discovered, bearing a relation to the liquor puris 
analogous to that borne by the colorless blood-cor- 
puscle to the liquor sanguinis, that the whole sub- 
stance was simply altered blood. 

This being shown to be untenable, the idea oc- 
curred that a homogeneous liquid was separated 
from the blood, in which the pus-corpuscles were 
developed by chemical precipitation or by a process 
of spontaneous generation. 

Next would come Donne's view, that this process, 
for it must have been in no essential point different 
from that just mentioned, belonged among the se- 
cretions, being analogous to the formation of bile, 
saliva, or urine. 

And as the rationale of secretion, and the physi- 
ology of the mucous membranes, became more fully 
understood, Hassall's theory that the pus-corpuscle 

* Op. cit., p. 250. 
18* 



206 LECTURES ON INFLAMMATION. 

should be regarded as an undeveloped epithelial cell 
pi^esented itself with much force. This idea evi- 
dently belongs to the modern school of pathology, 
based on physiological anatomy. 

The next step is the view so well set forth by 
Paget, in regard to the mutual relation existing be- 
tween pus and lymph. But, as was before remarked, 
there are exceptions to which this theory will not 
apply. These however would seem to be covered 
by that of Hassall. 

If now we can reconcile these two, and show that, 
while one applies to one set of cases, the other 
answers for the rest, and if we can so generalize the 
idea as to bring it into the shape of a law which 
shall cover the whole ground, it is obvious that we 
shall have done as much as could be looked for in 
the existing state of things. Possibly the further 
progress of investigation may overset all the theories 
of the present day, as has so often happened to 
theories which doubtless seemed to their supporters 
to be firmly established; but for this we need not 
look. All that can be done in any science is to 
reason upon the facts so far as they are known; all 
that can be learnt from the failure of former systems 
of philosophy, or from the demolition of former 
theories, is that those who would propose new ones 
should do so with modesty. 

In regard to the matter now in hand, it seems as 
if the modern German school had made a great ad- 
vance in establishing the theory of the legitimate 
descent of every cell from a pre-existing one. This 
theory has been already dwelt upon in connection 
with the development of lymph; and if it is of equal 



FORMATION OF PUS. 207 

force with, reference to the formation of pus, so that 
the two products can be shown to acknowledge a 
common or a like origin, the value of the step gained 
need hardly be pointed out. 

Pus, as is manifest, can be produced either upon 
a surface or within the substance of the tissues. It 
may be formed on the outside of the body, as in an 
ulcer, or in the substance of a tissue, as in the inter- 
stices between two muscles ; on the bronchial mucous 
membrane, or in the substance of the liver. But 
whatever its situation, it is to be regarded, accord- 
ing to the doctrines of the modern school, as the 
result of the proliferation, by division, of the cells 
either of connective tissue or of epithelium. In the 
words of Vircho w : 

" Pus is in our opinion a young tissue, in which, amidst 
the rapid development of cells, all solid intercellular sub- 
stance is gradually dissolved. A single connective-tissue 
cell may in a very short space of time produce several 
dozens of pus-cells, for the development of pus follows an 
extremely rapid course. But the result is of no service to 
the body ; proliferation becomes luxuriation. Suppura- 
tion is a mere process of luxuriation, by means of which 
superfluous elements are produced, which do not acquire 
that degree of consolidation, or permanent connection with 
one another and with the neighboring parts, which is neces- 
sary for the existence of the body."* 

In order to complete the theory, let us look at the 
application of this same idea to the formation of pus 
upon surfaces, or from epithelium. This is even 
more easily conceived of. Take for example the 
lining membrane of the urethra. Here there are 



* Cellular Pathology, p. 445. (Chance's Translation. ) 



208 LECTURES ON INFLAMMATION. 

several strata of epithelium, and if inflammation 
occurs, there is a very rapid throwing oft* of pus, 
without in the vast majority of cases anything like 
ulceration. It is much more reasonable to suppose 
a quickened formation of these epithelial cells, with 
at the same time a disposition to divide up into new 
cells, and an inability to acquire full development, 
than to imagine a homogeneous liquid poured out, 
certain atoms of which, by common consent, and 
by a spontaneous impulse, aggregate themselves 
together into organized forms. 






LECTURE VIII. 

THE STUDY OF PUS CONTINUED — ITS RELATIONS WITH LYMPH — WITH 
CONNECTIVE TISSUE — WITH EPITHELIUM — HISTOLOGICAL SUBSTITU- 
TION RELATIONS OF PUS WITH OTHER TISSUES PUS HAS NO SOL- 
VENT POWER RELATIONS OF PUS AND MUCUS — FINAL DESTINY OF 

PUS ITS OBJECT NOT PROTECTIVE PYOGENIC MEMBRANES, SO 

CALLED — ULCERATION — ITS RATIONALE — TYPICAL CASES — THE PRO- 
CESS A NEGATIVE ONE. 

"We have this evening, gentlemen, to continue the 
study of the subject of pus. You will recollect that 
at my last lecture, after speaking of the physical 
characters of this substance, I mentioned the various 
theories which have from time to time been pro- 
posed as to its mode of origin. I endeavored to 
show that none of those based upon the idea of 
chemical precipitation, of spontaneous genesis, or 
of the merely transitional character of the pus-cell, 
were satisfactory. Here, as in the case of lymph, 
the views of the modern German school, as set forth 
chiefly by Virchow, seem to me to accord best with 
the known facts. 

I took the ground, therefore, that pus was a pro- 
duct of the proliferation of cells previously existing. 
In this origin it is analogous to lymph; but while 
the latter may, and generally does, go on to a further 
development into more or less permanent forms, 
pus has as such reached its highest state. The 
lymph-cells may assume the character of fibrous tis- 

(209) 



210 LECTURES ON INFLAMMATION. 

sue, of epithelium, possibly even of nerves, although 
this latter idea rests upon an excessively slight basis 
even for so guarded a statement. Pus-cells, on the 
contrary, can undergo no change except in the way 
of degeneration and decay. 

The lymph-cell may be, owing to circumstances, 
a mere transition-form between connective tissue or 
epithelium and pus; the converse can never be the 
case. 

Hence we have at one end of the scale the normal 
structures, connective tissue and epithelium; at the 
other, pus; and between these, lymph. Inflamma- 
tion taking place, either lymph or pus may be de- 
veloped from epithelial or connective-tissue -ele- 
ments; if lymph, it may either assume the character 
of the progenitive structure, or degenerate into the 
effete condition of pus, whose only feature in common 
with living organisms is its cellular form. 

Such a theory covers alike cases in which, as in 
purulent conjunctivitis, we cannot admit the idea of 
a previous development of inflammatory lymph, and 
those in which, as in many abscesses, such a develop- 
ment manifestly precedes that of pus. Moreover, 
it does away with the necessity of a purely gratui- 
tous assumption of the power of spontaneous gen- 
eration of cell-forms in a homogeneous liquid. 

Wherever, then, we have connective tissue, or 
epithelium, in sufficient quantity, we may have pus 
as a result of inflammation. Should, as is often the 
case, perhaps it may be said always in interstitial in- 
flammations, a deposition of lymph first occur, then 
the pus will be in part derived from the conversion 
of this lymph, and in part from that of the tissues. 



RELATIONS OF PUS TO THE TISSUES. 211 

'Nov, 7 in the pus derived from a mucous surface, 
one is very apt to find upon careful examination 
that there are here and there mingled with the pus- 
cells the elements of epithelium, either normal, or 
in various stages of disintegration. And so also in 
the pus from an abscess, we often are able to detect 
shreds of broken-down connective tissue, which has 
simply become effete instead of going through the 
degenerative conversion into pus. Hence all the 
epithelium, or all the fibrous tissue, does not be- 
come involved in this process of pyogenesis. I 
think it may be said that it is only the young or 
newly-developed elements which are thus dwarfed 
as it were, and perverted; the fully-formed ones 
dying, indeed, from interference with their nutri- 
tion, but not going back first into their succulent 
and undecided form, to take a fresh start in a direc- 
tion which should lead them at length to the state 
of pus. 

An idea which will very probably have occurred 
to some of you in the course of this discussion, is 
that in one of the cases of suppuration now supposed, 
epithelium alone is present to be so changed, while 
in the other there is nothing but connective tissue 
available as a source of the pus. In the earlier days 
of physiology, this fact would very probably have 
been held as affording a conclusive argument against 
the theory that one and the same substance, — pus, 
— could be derived from the degenerative metamor- 
phosis of either of two tissues so different, in the 
eye of a superficial observer, as connective tissue 
and epithelium. But I think it may be stated as a 
view sanctioned by all that is know T n at present of 



212 LECTURES ON INFLAMMATION. 

the origin and development of the tissues, that, 
coming from a common stock of germs, the various 
elements assume their distinctive characters quite 
accidentally; according of course to a certain pre- 
conceived model, and not to any whim or caprice. 
Those germs, however, which become elaborated 
into the substance of the spinal cord, might just as 
well have been developed into epidermis or muscle, 
had their place been different. It is true that in 
the two instances just mentioned, of the nerve-tissue 
and muscle-elements, we have organisms which have 
received properties which set them entirely apart 
from such, for instance, as bone, connective tissue, 
or epithelium. And of these three, the earthy de- 
posit which has taken place in bone has given it a 
strongly distinctive character, wholly independent 
of the analogies which may be deduced from its 
form and the nature of its function. 

I have several times had occasion to allude to the 
relation between connective tissue and epithelium, 
but have not yet spoken definitely of it. Perhaps 
you will excuse my placing before you another quo- 
tation or two from Virchow's " Cellular-Pathologie," 
which will illustrate the point better than any words 
of my own could. 

In speaking of the so-called "law of continuity," 
proposed by Reichert, he says that — 

"It soon sustained the heaviest shocks, and of late has 
been so battered to pieces, that it is no longer possible to 
deduce from continuity any general criterion for deciding 
upon the character of a tissue. On the one hand, new facts 
have been continually presenting themselves in proof of the 
continuity of such tissue-elements, as according to Reichert 
should be separated toto ccelo, for example, of epithelial and 



HISTOLOGICAL SUBSTITUTION. 213 

connective tissues; instances have accumulated of cylindri- 
cal epithelium cells, prolonging themselves into fibres, which 
as such become attached to connective-tissue corpuscles. 
Indeed, there have quite lately been adduced numerous 
proofs that such cells may extend from the surface inwards 
to enter into immediate relation with nerve-fibres. Of this 
latter statement I must say that its correctness has not yet 
been proved to my satisfaction; but as to the former, that 
is a matter which seems likely to end in the establishment 
of a relation of continuity between the elements named. It 
would therefore appear that it is no longer possible to draw 
the line exactly between every kind of epithelium and every 
kind of connective tissue, except in the case of the former 
being tessellated ; when it is cylindrical, the boundary can- 
not but be very doubtful." 

After making similar statements in regard to the 
continuity of muscular and connective tissues, the 
author goes on to say : 

" Something else must therefore be substituted for the 
law of continuity. Here, I believe, is the essentially proper 
place of the doctrine of histological substitution. In regard 
to all tissues which are similar in their character there is 
a possibility, as occurs physiologically in various classes of 
animals, of the substitution of one by another of the same 
group in any given portion of the body; in other words, by 
a histological equivalent."* 

In support of this view, Prof. Yirchow adduces 
various examples of the substitution of one form of 
epithelium for another — that of the cartilaginous 
structure of the sclerotic coat of the eye in certain 
fishes, while in man that tunic is composed of dense 
fibrous tissue — that of bone where cartilage pre- 
viously existed — and finally that of striated muscle 
in some animals in parts which in others are made 
up of the non-striated kind. 






* Op. cit., Lecture III. 
19 



214 LECTURES ON INFLAMMATION. 

Let me recall to your minds an instance of this 
histological substitution which I mentioned to you 
when speaking of the development of lymph in in- 
flammatory adhesions; where, of a mass of adven- 
titious cells, while the interior ones assumed perma- 
nently the form of connective-tissue-elements, those 
on the surface acquired the character of more or less 
perfectly constituted epithelium. 

In applying this idea to the case of pus, it is only 
necessary, instead of supposing one starting-point 
from which a number of different forms are de- 
veloped, to reverse the plan, and imagine a deterio- 
ration of several varieties of tissue-elements into one 
common effete condition. 

And here the question may be most pertinently 
asked, what are those varieties which so deteriorate? 
Besides connective tissue and epithelium, there are 
often other structures, muscular, nervous, glandular, 
present in parts which are the seats of suppuration ; 
do they furnish pus-cells, or are they, as was stated in 
regard to fully developed fibrous elements, apt to be 
merely necrosed and thrown off* in the state of debris? 

To give a direct answer to these questions is not 
easy. A muscle may be inflamed, and pus may be 
developed in its substance — but whether the pus- 
corpuscles owe their origin exclusively to the degen- 
eration of lymph, and of the connective tissue which 
always enters into the composition of a muscle as 
such, or in part also to the proliferation of the 
special elements of the muscle, has not yet, so far 
as I know, been decided by actual observation. 

As to gland-tissue, it is certain that in many cases, 
as for instance in the abscesses in the parotid region 






PUS NOT A SOLVENT. 215 

which sometimes follow typhoid fever, the connec- 
ive tissue in the neighborhood of the gland, and 
not the gland itself, forms the seat of the inflamma- 
ion. And when, as in the lymphatic glands, these 
organs are themselves manifestly affected, there is 
scarcely anything present but connective tissue and 
epithelium; so that here there is no difficulty in 
assigning the source of the pus. 

As regards the share taken by nerve-structures in 
this process, it seems to me probable that the finer 
nerve-filaments which enter into the formation of 
the skin, for example, are broken down and de- 
stroyed much in the same way as the fully-formed 
connective tissue to which allusion was before made. 
It may be that some of the oil-drops and phosphatic 
salts which exist in pus are simply the debris of nerve- 
filaments. Xerve-truuks, when they run across the 
area of a suppuration, seem to maintain their integ- 
rity. I have seen the ulnar nerve stretching across 
the cavity of an abscess at the elbow; it was indeed 
in a state of incipient fatty degeneration, but its 
fibrous envelope was still perfect. 

I think it important in this connection to state 
formally that there is no ground whatever for the 
opiuion which had at one time, and perhaps still 
has, a place in the creed of many pathologists, that 
pus might act as a solvent of sound tissues bathed 
in it. This idea was probably derived from the ap- 
pearance often presented by bone which has been 
exposed by the loss of its periosteum, and in contact 
with a purulent deposit; such a portion of bone is 
apt to be brittle, roughened, and its surface irregu- 
larly worn away, as if worm-eaten. Actual experi- 



216 LECTURES ON INFLAMMATION. 

ment, however, has shown that the solvent power of 
pus is only imaginary; the appearances just men- 
tioned being produced simply by the failure of nutri- 
tion in the tissue, causing it to waste and decay. 
Bone that is killed may indeed crumble away, and 
be discharged either as a gritty debris or in actual 
solution, along with the pus of the abscess which 
existed around or alongside of it. 

Of this I have seen a striking instance in a soldier 
who was wounded by a small-sized conical bullet, 
which passed directly through the wrist from one 
side to the other. When he came under my care, 
some months after the receipt of the injury, a probe 
passed along the track of the ball came in contact 
with carious bone. Gradually, however, the dis- 
charge of matter became less and less, the openings 
closed up, and with the exception of deformity and 
loss of power, the member became perfectly sound. 
Here it is absolutely certain that the dead bone was 
brought into a state of very minute division, if not 
of entire solution; not because of any solvent power 
in the pus as such, but simply because the spongy 
character of the bone itself favored its disintegration. 

The idea, then, which I would substitute for this 
one of the solvent power of pus over tissues bathed 
in it, is simply that, the nutrition of such tissues 
being impaired, they become atrophied and disin- 
tegrated, and at length disappear. Undoubtedly, 
when pus is acid, and it is kept in contact with a 
portion of bone, it will like any other acid liquid 
decompose the earthy salts of the bone, and thus 
favor its atrophy and breaking down or absorption. 



RELATIONS OF PUS AND MUCUS. 217 

But this is very different from the idea that pus, as 
such, possesses a solvent power. 

The relation between pus and mucus has been, 
since the earliest days of microscopy, a subject of 
doubt. Perhaps, indeed, the study of the forms be- 
longing to those substances respectively only added 
to the confusion, since there was but a new element 
introduced into the question, without any direct in- 
crease of light on the main point. TV r e must go 
back of these structures, and look at the entire 
group which they form with epithelial cells, in order 
to arrive at anything like a satisfactory idea of their 
relation. 

AVe have sometimes, when a mucous membrane 
is not very severely irritated, or in the earliest stages 
of its inflammation, a flow of mucus, a glairy and 
more or less viscid liquid, from its surface. Placed 
under the microscope, this liquid is seen to be al- 
most homogeneous, but containing some rounded 
corpuscles, sometimes with more or less fully-formed 
nuclei, sometimes without. Acetic acid often brings 
out nuclei in these bodies, which had not previously 
been visible. Mingled with elements of this kind 
are apt to be epithelial cells, which very generally 
are effete and breaking up. Such appearances may- 
be found in almost any specimen of mucus from the 
nose or bronchial tubes in cases of catarrh — and 
nothing is added to them unless the inflammation 
becomes very greatly aggravated. 

Here then we have an increased development of 
epithelial forms, but in a very crude and immature 
state ; and this it seems to me is the explanation of 
mucus and its origin. 

19* 



218 LECTURES ON INFLAMMATION. 

If the parts become more and more inflamed, we 
have more and more the characters of true pus in 
the discharge. There is a wider deviation from the 
ordinary normal type of the elements developed on 
the surface, and those which arise are no longer 
merely crude, but they are derived from a rapid 
proliferation of the existing cells, under the influ- 
ence of a powerful stimulus. And the mucous dis- 
charge will acquire the gross appearances of pus 
long before the microscope will reveal a change in 
the character of the contained elements. Hence 
there is a gradual shading off from the normal 
homogeneous secretion of a surface so irritated to 
the fully-formed purulent discharge. At the very 
first, perhaps, there is simply an increase of the thin 
liquid, for instance, which comes from the Schnei- 
derian membrane, and which passes off by mere 
evaporation. The quantity of it is so much larger 
than normal, that it flows away. Then there comes 
a period when the epithelial cells, in their fully- 
formed state, are rapidly shed — and now new cells 
are also imperfectly formed, not distinctly nucleated 
— mere abortions, if we may so speak, of what should 
have been epithelial cells. Still later, there may be 
an actual formation of pus — the cells of the lower 
layers of epithelium undergoing a process of divi- 
sion or proliferation into what we now know as the 
pus-corpuscle, a product of such degenerative pro- 
liferation either in epithelial cells or in those of 
inflammatory lymph. 

Now the question may be asked, does this division 
of the nucleus of the pus-cell ever go on to comple- 
tion, and finish by inducing a like division in the 



PUS AN ULTIMATE FORM. 219 

cell itself, so that in place for instance of one pus- 
cell with three nuclei, there exist three with one 
nucleus each, or one with one nucleus and another 
with two? It is difficult to give a positive answer 
to this question, since we can only take the pus-cell 
as we find it, and we do not know of any one speci- 
men of it whether the effort at division of the 
nucleus has not exhausted its energies in the way 
of proliferation. For it must be remembered that 
the pus-cell is the exponent, if we may so speak, of 
an irritative degeneration — of a state of things in 
which while the part is stimulated, it is less able to 
respond fully and in the way of actual growth to 
the stimulus ; and hence, owing to its parentage it 
has form — owing to the excitement which gave rise 
to its development it is impressed with a tendency 
toward multiplication — but at the same time, owing 
to the marked degree in which the normal condi- 
tions of nutrition were set aside, it has a less en- 
dowment of vital power than the regular offspring 
of the structures concerned. 

Hence, no matter how effective the proliferation 
of any one pus-corpuscle might be, it would only 
augment the number of like elements; and there 
is no ground for assuming that this proliferation 
can go beyond the first generation. That is, as- 
suming that from one connective-tissue cell, as Vir- 
chow says in the passage already quoted to you, 
' several dozens of pus-cells are produced in a short 
time; not one of these has any tendency to assume 
any higher type of development; they may possibly 
every one of them tend to divide into several new 
forms, and thus to augment the quantity of pus 



220 LECTURES ON INFLAMMATION. 

present; so that, had we examined the part a little 
later, there would have been more pus developed in 
it. But this power of proliferation goes no further; 
it cannot be substituted by a tendency in the pus- 
corpuscle to form a fibre, or to take on the charac- 
ter of an epithelial cell. And it would need more 
positive proof than now seems likely to be attain- 
able, to show that the several cells, so generated by 
division, possessed any tendency themselves to un- 
dergo a like fissuration. 

Whether this interpretation of the multinuclear 
character of the pus-corpuscle be correct or not, it 
is still probable that at the time when that organ- 
ism comes under the eye of the microscopist, the 
power of proliferation is not possessed by it — so 
that, for example, such a cell containing three nuclei 
might be watched for hours, and it would not un- 
dergo separation into three new cells. For, accord- 
ing to the views which have been presented in the 
course of these lectures, it cannot be said that the 
agglomeration of atoms which form a pus-cell has 
received a power of independent life, so that they 
go on by virtue of their own force to divide into a 
progeny, somewhat as the womb of a parturient 
woman may empty itself after her death. Nor can 
it be said that at the time of the first formation of 
pus-cells there is such an impetus given in the direc- 
tion of life as can only be exhausted after several 
generations. The fact is, that the first production 
of these cells, and every succeeding one, simply de- 
pends upon favoring external conditions. No tissue, 
organ, or congeries of cells has the power of setting 
itself to work to form pus. Should its nutrition be 



FIXAL DESTINY OF PUS. 221 

disturbed in a certain way, an indirect result is that 
instead of the formation of new healthy or normal 
tissue-elements, there is a substitution for these of 
pus-cells, — a suppuration. 

As to the final destiny of pus, it is decided alto- 
gether by circumstances. Sometimes, as when an 
ulcer is properly cared for, or when an abscess is 
opened, it simply is removed from the economy, 
and shares the fate of other refuse animal matters. 
Sometimes it dries up in the atmosphere, and by 
an admixture of dust and other floating particles 
acquires the firm consistence of what we know as a 
scab. 

This drying up of pus sometimes seems to be 
accomplished upon a certain definite plan, as for 
example in the case of the smallpox pustule. Here 
the cuticle is puffed up by the presence beneath it 
of a deposit of purulent liquid. After a time the 
central portion of the raised cuticle becomes de- 
pressed or drawn in, and the contents of the pustule 
acquire a thicker and thicker consistence, until at 
length they dry up altogether. Whether the watery 
part of the pus is absorbed, or evaporates through 
the scab, I do not know; but I am inclined to 
think that the former is the case. Certainly the lat- 
ter part of the history of a smallpox pustule differs 
materially from that of acne, impetigo, or any other 
sore of like kind, in which the discharge of the 
matter is followed by the filling up and healing of 
the breach. 

Occasionally something similar seems to take 
place in abscesses, which dry up and diminish in 
size, and are said to have been absorbed. This is 



222 LECTURES ON INFLAMMATION. 

most apt to occur in suppurations of lymphatic 
glands, and where the inflammation preceding the 
development of the pus has not been either very 
acute or very severe. But in fact the pus as such 
is not absorbed; it is only the liquid portions of it 
which are removed in this way, while there is left a 
cheesy, inspissated mass, which may ultimately be 
chemically broken up, and itself disappear. 

Pus, then, never assumes a permanent relation to 
the economy as lymph so often does. It is either 
discharged altogether and at once, or remains on 
sufferance, as it were, until a slower process of re- 
moval can be effected. I shall have occasion pres- 
ently to discuss the possibility of its entering the 
circulation and giving rise to further trouble, as 
many pathologists have supposed that it did in the 
cases of so-called purulent absorption. 

An idea has been very prevalent, and perhaps 
still obtains general acceptation, that pus is a bland 
secretion, which is intended to protect the parts be- 
neath it, as in the case of an ulcer. No doubt its 
presence is advantageous in this way, but I do not 
think this warrants us in speaking of it as a " natural 
dressing." For, as was remarked in the case of 
lymph, there are so many instances in which the 
formation of pus gives rise to extreme inconve- 
nience, that we might just as well take the view 
that this latter was the object for which it was in- 
tended. The evil, like the good, is incidental. As 
in the case of every other natural phenomenon it is 
according to circumstances whether the comfort of 
living beings shall be promoted or interfered with. 
I would therefore regard the law under which pus 



EFFECTS OF PUS INCIDENTAL. 223 

is formed as one of that system of laws which govern 
life. "WTien the processes of life, as manifested in 
any mass of cells, are deranged in the way which 
we call inflammation, — when the nutrition of that 
mass of cells is, according to the views already set 
forth, at the same time stimulated and weakened, — 
there is a more rapid proliferation, a quicker but a 
less purposive formation of new cells. 

Moreover, a close scrutiny of the conditions under 
which an inflamed part is placed, and by which it is 
compelled to give rise to certain new products, — i 
lymph or pus, — will show that there is never either 
a capricious tendency one way or the other, or a 
prudent choice as to which will best serve the com- 
fort or welfare of the part or of the animal. As I 
have several times before urged, the material ele- 
ments blindly obey the immediate forces brought to 
bear upon them. Given the circumstances under 
which, according to the law impressed by the Crea- 
tor upon all living tissues, pus is formed, — pus will 
be formed, be it on a surface where it acts as a bland 
protective layer, or under a tough fibrous membrane 
where it gives rise to the severest agony. As well 
might an unsupported stone refuse to obey the law 
of gravitation because a man stood directly under 
it, as the tissues pour out pus for their own dressing. 

Before leaving this special topic of the natural 
history of pus, I must say a few words as to the 
very commonly received idea that a sort of special 
organ is formed in some cases, whose function is to 
secrete or give rise to pus, and which is called the 
pyogenic or pus-forming membrane. It is evident 
at once that such an idea is inconsistent with those 



224 LECTURES OX INFLAMMATION. 

which. I have set forth in regard to the mode of ori- 
gin and histological position of pus. Those in- 
stances which seem to support it most strongly are 
cases of lumbar abscess. Preparations have been 
made, and are represented in many works on sur- 
gery, showing a sac, shaped according to the press- 
ure of surrounding parts, and extending from the 
lumbar region even far down along the thigh; this 
sac having invested the purulent collection during 
life. 

If, however, we examine any case in which a sinus 
or fistula has existed for a length of time, we find 
an entirely analogous membrane; and in very many 
old ulcers the same is true. 

The fact is, the idea of this membrane is closely 
allied to that of pus being a secretion; and when 
we give up this latter, assigning to the pus-corpuscles 
the place merely of an organic individual which so 
far as its relation to the living economy is concerned 
is an abortion, we must abandon also the notion of 
a specially constituted membrane for its develop- 
ment. But it is readily seen that the presence of a 
mass of pus, insinuated as it were among the tissues 
and therefore tolerated by them, will keep up only 
a slight degree of irritation, — -just enough and no 
more perhaps to induce the continual formation of 
a layer of new lymph to supply the place of that 
which, as the disease advances in extent, breaks 
down into pus. Just in the same way the continual 
flow of pus and other matters along a sinus or fis- 
tula will not only it keep open, but the tissues 
bounding it will be constantly stimulated to just 
such a degree that new lymph will supply the place 



RELATIONS OF PUS AND LYMPH. 225 

of that which proliferates into pus. In either case 
the process is altogether analogous to that of the 
breaking clown of the central portions of a mass of 
lymph in the formation of an abscess, as described 
by Paget in the passage which I quoted to you in 
my last lecture. The only difference is that there 
is in the ordinary acute abscess a very thick layer of 
lymph about the central mass, while in the chronic 
abscess or in the sinus there is generally a very thin 
one, and it is often sharply defined. Sometimes, as 
in the case of a fistula in ano, there remains around 
the channel quite a quantity of solidified lymph, 
which even forms a marked swelling about the outer 
orifice — but this is usually in acute cases; in such 
as have existed for a leiis-th of time the encasing 
and less sharply defined portions of the adventitious 
substance are absorbed, and the morbid product is 
reduced simply to the slender tube of lymph cells, 
the inner layer of which proliferate and produce 
pus-cells, just as a layer of epithelium would. 

Perhaps a still more striking example of this con- 
dition of things may be found in the formation of 
a perineal fistula. Generally there is here a well- 
developed abscess, with all the usual local phe- 
nomena. "When this breaks or is opened, the swell- 
ing goes down in a surprisingly short time, and the 
sinus becomes established, just as in the other case. 
But here there is apt to be rather more irritation 
than in fistula in ano, on account of the passage of 
the urine being more frequent and more stimulating 
than that of the feces, while the parts are more 
movable and more sensitive. 

Equally striking, and unfortunately of late years 
20 



226 LECTURES ON INFLAMMATION. 

even more common under the observation of most 
of ns, are those cases of gunshot wounds in which 
the presence of foreign bodies or of dead bone gives 
rise to the formation of sinuses, sometimes long and 
tortuous. The walls of these sinuses are often so 
tough and firm as to defy the distending force of 
the finger pushed along them; and from them there 
takes place a continual weeping of a purulent liquid, 
in which, indeed, from the dense and fully-formed 
character of the elements generating it, the pus-cor- 
puscle is but scantily developed. Any one unfa- 
miliar with anatomy would perhaps scarcely believe 
that a firm, smooth, apparently well organized and 
permanent tube such as so often constitutes one of 
these sinuses could be wholly adventitious and tem- 
porary. 

But the final overthrow of the doctrine that there 
is such a thing as a special pyogenic membrane is 
derived from microscopic observation, which shows 
that what has been so denominated differs in no re- 
spect from other deposits of lymph which have by 
the force of circumstances been maintained and 
brought to the state of fully-developed connective 
tissue. Thus the wall of a sinus contains exactly 
the same elements, similarly arranged, as an adhe- 
sion between the two surfaces of the pleura. 

It seems to me that the present is the most appro- 
priate point at which to take up the study of ulcer- 
ation and granulation; two processes which could 
hardly be omitted in any discussion of the general 
subject of inflammation. What I shall have to say 
about them, however, will be rather in the way of 



ULCERATION. 227 

applying principles already laid down, than of tak- 
ing them up separately as constituting special and 
peculiar modes of morbid action. 

To begin then with ulceration. I think it may 
be regarded as always the result either of injury or 
of a failure of nutrition; often these causes are com- 
bined. Perhaps I need hardly mention that Hun- 
ter described the "ulcerative inflammation" as a 
special form, side by side with the "suppurative," 
the "adhesive," and the "sphacelous." And you 
are probably all aware that in most works on sur- 
gery, ulcers are made the subject of a separate 
chapter, and divided into various classes, such as 
the simple, irritable, and indolent, — the simple and 
specific, — the healthy and unhealthy. Clinically, it 
may be well enough to employ such terms; but 
they cannot be looked upon as scientifically correct. 
The process of ulceration I believe to be always and 
everywhere the same, but to present in different 
cases different features, by reason of surrounding 
circumstances, chief among which are the state of 
the constitution, and the anatomical structure of 
the part which is the seat of the disorder. 

Ulceration is a step beyond mere abrasion. The 
limits between them are not always clearly defined; 
as some of you are aware, it has been within the 
last few years a subject of active controversy whether 
in cases of so-called uterine disease there is or is 
not ulceration of the visible part of the womb. Such 
a point would seem to be easily enough determined 
by actual observation, but the fact is that what some 
physicians call ulcerations, are in the opinion of 
others abrasions only. 



228 LECTURES ON INFLAMMATION. 

We need not, however, concern ourselves now 
with these doubtful cases — especially as their clini- 
cal history shows that the local disorder, if it be 
indeed the starting-point of the trouble, is soon 
merged altogether in the host of other and more 
urgent symptoms presented. 

Ulceration, as I have remarked, seems to be al- 
ways the result either of injury or of a failure of 
nutrition, or of both these conditions combined. 
When a piece of skin is sliced off with a cutting 
instrument, a sore is left which in everything but 
its origin resembles the so-called simple or healthy 
ulcer. Such a wound, if produced upon a healthy 
and well-nourished person, will tend at once, or at 
any rate as soon as the first accession of inflamma- 
tion subsides, to heal up. And so also will an ulcer, 
if placed in altogether similar conditions. On the 
other hand, if the general health be undermined, a 
previously cicatrizing wound will cease to contract, 
and assume the character usually ascribed to an 
ulcer. 

There are two cases which may be taken as typi- 
cal of ulceration. The first is that of a bedsore, in 
which by constant pressure the nutrition of a certain 
portion of skin is to such an extent interfered with, 
and its texture so mechanically injured, that it in- 
flames, and sometimes after a very short time, breaks 
down ; so that where there was healthy and sound 
skin, covered by epidermis, there is a raw and sup- 
purating surface. 

The other case is that of a common sore leg, such 
as may be seen in all the phases of its existence in 
any almshouse. Here, although very often a blow, 



ULCERATION. 229 

or the rubbing of a boot-leg on the shin, is men- 
tioned by the patient as having originated the dis- 
ease, the cause alleged is usually insufficient to 
account for the size and depth of the ulcer when 
it comes under observation. Sometimes no such 
cause is assigned; the patient has simply found the 
skin broken, and the sore has continued to enlarge 
more or less rapidly. But here we always find the 
tissues of the part relaxed and flabby, and almost 
invariably there are evidences of a sluggish circu- 
lation in the swollen and tortuous veins. 

Now there is a very strong analogy between these 
two cases in the anatomy of the parts concerned; 
that is, between the portions of skin over the prom- 
inent bony points in the back, over the trochanters, 
or over the heel, and that which covers the tibia. 
In neither is there much of a vascular supply except 
at the periphery, and in both, therefore, the nutri- 
tion is readily impaired. And this fact alone shows 
why, upon the infliction of any mechanical injury, 
there should be not only a marked effect in the way 
of inflammation at the point itself, but a tendency 
in the surrounding tissues to yield to the disturb- 
ance, as well as to the mere strain upon them; thus 
giving rise to an ulcer. 

In further illustration of this, take the opposite 
case of a portion of tissue such as the skin of the 
cheek, having an abundant vascular supply, and 
closely attached to the subjacent parts; I think it is 
obvious that if the same amount of injury, whether 
by a blow or by mere pressure, were inflicted here, 
the structures in the neighborhood would be, both 

20* 



230 LECTURES ON INFLAMMATION. 

by reason of their better nutrition and of their more 
efficient mechanical support, less likely to undergo 
ulceration, which in fact very seldom occurs at such 
points. 

And either by mechanical injury, be it by actual 
violence or by wearing away, or by failure of nutri- 
tion, the loss of substance which gives rise to an 
ulcer may always be accounted for. Obviously, if 
the part is put in favorable conditions, the loss will 
be repaired; if not, the ulcer will remain. 

The point at which I wish to arrive is, that neither 
the origin of an ulcer, nor its spreading, is due to 
any mysterious power or tendency residing in the 
tissues. An ulcer is a negative affair altogether — 
the elements at a certain point on the surface lose 
their vitality as such, by reason of a failure in the 
conditions needful for their nutrition. It amounts 
to the same thing, be the cause of the failure me- 
chanical, chemical, or vital. 

-Now, let us inquire, what is the anatomy of an 
ulcer? In the first place, the epidermis, or in a 
mucous membrane the epithelium, must be wholly 
gone — and the tissues beneath would be exposed, if 
it were not that under such circumstances they un- 
dergo formative irritation, and their cells by pro- 
liferation produce a layer, perhaps a great many 
layers, of lymph-cells. In a sloughing ulcer this 
will be apt not to occur, because the formative force 
of the tissue-elements is lost, as indeed is implied in 
the fact of their mortification. Hence when the 
slough in such a case is thoroughly cut away, we 
come down to muscle, nerve, etc. But occasionally, 
even in gangrenous ulcers, there is an abundant for- 



ULCERATION. 231 

mation of lymph, the outer layers of which, how- 
ever, undergo the process of death and putrefaction 
almost as soon as they acquire their organization. 

Now in any case an ulcer must be either spread- 
ing, stationary, or healing. The rationale of its 
spreading has been already set forth. If it remains 
stationary, it does so simply because the conditions 
needed for its healing are not present. Let these 
conditions be furnished, and it will be utterly im- 
possible for the ulcer to do anything but heal. This 
process is accomplished by means of what is com- 
monly known under the name of granulation. It 
is entirely analogous, in my opinion, with the other 
developments of adventitious tissues in the body, 
and is accomplished by the same means. I must, 
however, defer its detailed consideration until my 
next lecture. 



LECTTIKE IX. 



GRANULATIONS — CHARACTER OF IN A HEALING SORE — ANALOGY WITH 

FORMATIONS OF LYMPH ELSEWHERE — FORSTER'S DESCRIPTION 

ANALOGY BETWEEN AN ULCER AND AN ABSCESS — MODE OF HEALING 
OF AN ULCERE— EVERY STEP OF THE PROCESS DUE TO IMMEDIATE 

CAUSES CICATRIZATION MODIFICATIONS OF INFLAMMATION BY 

STRUCTURE OF PARTS PARENCHYMATOUS TISSUES MUCOUS AND 

SEROUS MEMBRANES. 

At the close of my last lecture, gentlemen, I was 
about to take up the subject of granulations. We 
had studied the natural history of the two products 
of inflammation, lymph and pus, and had then con- 
sidered in a general way the process of ulceration. 
Now it may have seemed as if this latter topic had 
been dealt with too summarily, or at least as if the 
importance always assigned to it in surgical writings 
should bespeak for it more extended notice. But 
in fact we have not yet done with it. The points 
which had engaged our attention were, the causa- 
tion and the anatomy of ulcers; and I had stated, 
that the subsequent course of any such sore must be 
either to spread, to remain stationary, or to heal. 
Should it spread, it must be either by the continued 
action or the extension of the prime cause of the 
lesion; should it remain stationary, it must be simply 
because there are not present the conditions which 
would favor its healing. But if it should heal, it 
( 232 ) 



GRANULATION. 233 

must be by means of the process which we have 
now to study — by granulation. 

An ulcer once established, that is, the tissues con- 
stituting a cutaneous or a mucous surface being de- 
stroyed to a certain extent and depth, there will 
ensue, by reason of the formative irritation of the 
exposed organic elements, a proliferation of those 
elements, with the result of covering them with a 
layer of new, young cells, — or in other words, with 
a layer of lymph. This lymph will in almost every 
instance become developed into a permanent rela- 
tion with the parts beneath, unless, indeed, the cir- 
cumstances are so unfavorable that it either sloughs 
or degenerates into pus, in which case the ulcer is 
still further deepened. 

Under the best auspices, however, this organized 
layer of lymph will enter into permanent relation- 
ship with the subjacent tissue, and its cells will then 
undergo a like proliferation, giving rise to another 
layer, and so on. "What very often happens, again, 
is that this process of building up goes on well for 
a time, and then becomes checked. It is at this 
stage of affairs that ulcers usually come under the 
eye of the surgeon. In other words, the ordinary 
anatomy of an ulcer is as follows : a gap in the sur- 
face-tissue is partly filled up by a deposit of organ- 
ized lymph, so that we have a cavity of greater or 
less depth, bounded everywhere by this adventitious 
substance. Sometimes the deposit is so abundant 
as to bulge up and constitute what is called a fun- 
gous growth, so that instead of a cavity there is a 
protrusion; of which one of the best instances may 
be seen in what is known as the toe-nail ulcer. 



234 LECTURES ON INFLAMMATION. 

Perhaps I need scarcely state that this exuberant 
formation of lymph does not indicate an excess of 
organizing force, but rather the contrary. The 
granulations which spring from healthy and well- 
nourished tissues are florid, smooth, and firm, and 
tend to become quickly conformed in general shape, 
as nearly as may be, to the normal type of the 
part. Often the superabundant granulations are 
pale, flabby, and irregular, and bleed at the slight- 
est touch. Such a mass, looking very much like 
the lymph which is apt to be found infiltrating 
the areolar spaces of limbs affected with degenera- 
tive disease, may very commonly be seen occu- 
pying the space between the edges of ill-condi- 
tioned stumps. It is in fact due to precisely the 
same causes. The elements to whose proliferation 
the lymph-cells are owing, are stimulated to excess, 
but are at the same time weakened; they originate 
new cells quickly, but this very fact prevents those 
new cells from establishing themselves in such rela- 
tions with the progenitive tissues as are necessary 
to their permanent development. Hence, in such a 
state of affairs, we see just what we might have ex- 
pected; an abundance of new elements, remaining 
in this state of youth because the circumstances 
under which they are placed do not favor their be- 
coming mature. 

And here I may say what I omitted in speaking 
of the ultimate development of lymph, that such a 
transition from the status of young, crude cells to 
that of fully-formed connective tissue, and certainly 
the further change undergone by some of the cells 
into epithelium, cannot occur so long as the inflam- 



RATIONALE OF GRANULATION. 235 

matory process continues. It is only when the ab- 
normal stimulus ceases to act, and the part returns 
as nearly as possible to its healthy condition, that 
this elaboration of the adventitious substance begins. 

~No very deep knowledge of anatomy is needed to 
enable one to affirm that nothing like the crude and 
undeveloped lymph just alluded to belongs any- 
where in the healthy body. The replacement of 
such cells as become effete, the generation of such 
as are needed by any fresh stress upon a part, takes 
place without any palpable accumulation of masses 
of the as yet unclassified elements, if we may so call 
them. But when an agency of such a character and 
energy as to excite inflammation is brought to bear 
upon a part, the formative irritation which ensues is 
exhibited in this very way, by the rapid production 
of young cells, which may either remain in their 
primary condition as lymph, or become converted 
into the degenerative elements of pus. 

If I may be allowed the comparison, not in every 
respect complete, the excitement which raises up 
large bodies of raw recruits must in a great measure 
subside, and give place to a steady determination 
and a rigid discipline, if the result is to be the 
organization of an efficient army. 

To return then to the formation of granulations. 
It is carried on, I maintain, in the same way as that 
of adhesions or similar deposits of lymph; or rather, 
it is the self-same process, presenting a different 
aspect because going on in a different situation. 
And, as was argued in relation to the mode of 
establishment of the vascular supply in such cases, 
the vascularization of the lymph which goes to make 



236 LECTURES ON INFLAMMATION. 

up granulations is due to the attraction of the ele- 
ments of that lymph for the blood contained in the 
neighboring capillaries. 

The anatomy of the structures so built up has 
been most admirably described by Forster, a recent 
German writer, as follows : 

" They have always the relation of products of inflamma- 
tion to the tissues and organs from which they arise, and 
from these their elements are in part formed; these elements 
are : vessels, mainly capillaries, connective tissue more or 
less fully developed, and cells having the general character 
of pus-cells. The mode of formation and histological rela- 
tions of granulations are best shown by examining them in 
some of those organs in which they are most commonly 
presented. 

"We find granulations oftenest at the bottom and edges 
of ulcers in the skin; they form here very numerous, red, 
rounded elevations, varying in size from that of a millet seed 
to that of a pea, sometimes larger and more prominent 
granular masses. Now how do these formations arise from 
the normal tissue-elements ? by what processes is this lat- 
ter deprived of its proper texture and converted into such 
granulations ? If we make thin perpendicular sections 
through the tissues at the edge of an ulcer of the skin, which 
is increasing outwards, and at the edges of which within a 
few days normal skin has been changed into granulations ; 
and put these sections under the microscope, we see as 
follows : In passing from the healthy parts towards those 
which are altered, we see the most remarkable changes in 
the vessels of the papillae ; the capillaries which run up into 
and down out of the papillae, become wider and longer, and 
seem to become more tortuous than usual. Then the tor- 
tuosities become more numerous and larger, and run into 
one another almost perpendicularly, until at last the papilla 
becomes filled with a tangle of such windings, too intricate 
to be distinguished by the eye ; since all the capillaries are 
equally distended with blood, they come out very markedly 
in such preparations. While this alteration goes on in the 
vessels, the connective tissue of the papilla likewise grows, 
and increases in breadth ; the several papillae come nearer 



ANATOMY OF GRANULATIONS. 237 

together, and since at the same time the skin itself becomes 
swollen, their bases widen, and they become as it were fused 
by degrees into one another. The connective tissue of the 
skin and of the papillae thus becomes more homogeneous, 
softer, and the nuclei of the connective-tissue corpuscles 
show more clearly than they previously did ; while in the 
vessels of the skin the same changes in shape and calibre 
take place as were before mentioned in those of the papillae. 
The epidermis shares at the same time in the alteration, in 
that the cells of the mucous layer increase in number, and 
this seems enlarged, and like all the other tissues softer and 
more delicate. The nearer we come to the edge of the 
ulcer, the more marked are all these changes, until the pa- 
pillae and the corium are blended into a mass, in which only 
above, at the free edge, can any trace of indentations be de- 
tected ; their substance has become extremely soft, the con- 
nective tissue homogeneous, and interspersed with longish 
nuclei and spindle-formed cells in greater or less number, 
but especially with pus-cells. The capillaries run up out 
of the cutis and spread themselves out above in numerous 
windings ; it is evident that the granular character of the 
surface is due to these numerous capillary loops pressing 
their way toward the exterior. The capillaries of the dif- 
ferent papillae are now crowded closely together, and as it 
would seem, are also united by anastomoses. The cells of 
the mucous layer become gradually replaced by pus-cells, 
and those of the horny layer pushed off entirely, so that the 
conversion of this portion of the cutis into a granulation is 
completed." 

The excellence of this description seems to me 
the best apology, if any is needed, for so lengthy a 
quotation. 

Now the great rapidity with which pus is formed 
upon granulating surfaces can be readily accounted 
for when their anatomy and mode of construction is 
once understood. Here is going on an abundant 
generation of new cells; they are crowded together, 
and while some acquire a settled relation to one 
another and to the blood-vessels, others, and these 

21 



238 LECTURES ON INFLAMMATION. 

a very large proportion of the whole number formed, 
are unable, as it were, to gain a foothold, and take 
on the lower and degenerative character of pus- 
corpuscles. It needs scarcely perhaps to be men- 
tioned that there is a striking analogy between this 
condition of things and that which obtains in an ab- 
scess, as already described. The only difference lies 
in the fact that in the latter case the granulations 
and the pus are in the cavity of a hollow sphere, 
from w T hich the air is excluded, while in the ulcer 
they are on a surface, theoretically if not actually 
hollowed out. 

This is a true histological substitution. "When 
we wipe off a drop of pus from the surface of a 
granulating sore, and put it under the microscope, 
we are looking at millions of cells, every one of 
which, under favoring external circumstances, would 
have assumed a permanent place in the economy. 
And when we examine a thin section of a mass of 
granulations, we are looking at hundreds of cells, 
every one of which, had it not met with a suitable 
opportunity for settling, if I may so speak, would 
have lost all of organization but the form, and as a 
pus-cell become practically effete. 

Moreover, we find in the circumstances of the 
case a perfectly simple explanation of the difference 
between the organization of a mass of lymph effused, 
for instance, between two serous surfaces, and that 
of a mass of lymph developed in an ulcerated patch 
of skin. In the former case the vessels are in very 
small proportion to the quantity of lymph, in the 
latter case they are abundant. In the former case 
there is a very long distance between many of the 



HEALING OF ULCERS. 239 

lymph-corpuscles and the capillaries, in the latter 
case a very short one. In the former case the in- 
nervation which, as is universally conceded, is neces- 
sary for organization and nutrition, is obviously 
more complete and energetic than in the latter. 
Lastly, it may perhaps be that the great readiness 
with which, upon a granulating surface, some of the 
cells may lose their connection and be thrown off, 
enables those which are not so detached to acquire 
their status more quickly and completely than they 
otherwise would. 

The position I would take, therefore, in regard 
to the process of granulation, is that it is wholly 
analogous to the development of lymph elsewhere 
into adhesions; the only difference between the two 
cases lying in the incidental circumstances under 
which the adventitious elements are placed. 

In order to complete the application of the prin- 
ciples laid down in earlier portions of this course of 
lectures, allow me here to digress for a few moments, 
and to speak of the method in which the healing of 
an ulcer is perfected. 

I have several times had occasion to bring for- 
ward the idea that there is for every class of animals, 
for every individual of each class, and for every unit 
of organization, a certain programme to which it is 
ordained to conform, as well as a certain anatomical 
type. And it must be evident that the occurrence 
of ulceration, from whatever cause, is a departure 
from this type, so far as the affected part is con- 
cerned. The observations of Paget and others show, 
that if portions of crystals are broken off, and they 
are then placed in favorable conditions, they tend 



240 LECTURES ON INFLAMMATION. 

to repair their loss, and to assume again their nor- 
mal shape. It can hardly "be supposed that a single 
cell, if so injured, could fail to lose its life altogether. 
But of a mass of cells forming an organ, we know 
that it is otherwise. "We know that the develop- 
ment of new cells fills up, for example, the cavity 
left by an ulcer or a wound. 

On the other hand, however, we have abundant 
instances in which the approach to the normal ana- 
tomical type is lamentably incomplete, as in the 
faulty cicatrization of burns. If there were pre- 
siding over every process of repair that mysterious 
sanative agency spoken of as nature, it is surely 
strange that she should be so careless as not to 
forestall the mischief which so often ensues in such 
cases. 

"What I would again insist upon is, that from first 
to last the changes which take place in matter, or- 
ganized or unorganized, are due to the immediate 
operation of surrounding circumstances — so that the 
formation and modelling of an adhesion between two 
serous surfaces, of the cicatrix of a burn, or of that 
of a common ulcer of the leg, constitute one and 
the same process, and obey the same laws. 

Hence, when the granulations which fill up the 
cavity of an ulcer cease to be stimulated to further 
proliferation, those which lie at the edges of the 
sore no longer generate pus-cells; they become dry, 
and gradually acquire the same relation to those 
below them that the epidermis has in the unbroken 
skin. They become also insensitive to the irritation 
of the atmosphere, as the epidermis is. How far 
they assume a resemblance to the cuticle, in their 



PROCESS OF REPAIR. 241 

minute anatomy, I cannot say. Just so far as they 
are subjected to influences which favor their devel- 
opmental changes, they will be developed, and no 
farther. It would be just as easy, and in my opinion 
just as rational, to suppose that striated muscular 
fibre might be formed on the surface of a cicatrix, 
as that regular epidermal cells may be. 

If these statements be correct, we must lay aside 
altogether the idea that when a loss of substance 
occurs in any organ, there is a deliberate attempt, 
on the part of the neighboring tissues, the organ 
itself as such, or the economy, to replace what is 
gone, and to restore the normal shape. In any such 
case, the adjoining cells undergo formative irrita- 
tion; they proliferate, some of their progeny be- 
coming permanent in the animal, others being 
thrown off as pus. Those which become perma- 
nent assume the character, generally, of connective 
tissue, some of them probably becoming in a meas- 
ure allied to epithelium or epidermis. 

It does not seem to me that in such a view of the 
process of repair of injuries there is involved any- 
thing like a slighting or a want of recognition of the 
Divine power in the regulation of the material world. 
It would be an undeniable miracle if, after the am- 
putation of a thigh, or even of a finger, the lost 
part should be reproduced; and if there were but a 
clumsy attempt at such restoration, it would be no 
less a miracle, if we can conceive, with due rever- 
ence be it said, of a badly performed miracle. And 
yet there is no middle ground; if there is ever a 
deliberate effort at reconstruction of a portion of 
any organ which is destroyed, then there should be 

21* 



242 LECTURES ON INFLAMMATION. 

a possibility, at least, of tlie re-formation of an en- 
tire limb. Certainly it is more in accordance with, 
all else that is known of natural processes, to trace 
the working of one general, simple law, which 
makes the production of lymph the result of forma- 
tive irritation, responded to blindly and of necessity 
by the tissues. 

In the clear and beautiful exposition of the sub- 
ject of the restoration of lost parts in some of the 
lowest living forms, with which Paget introduces 
the discussion of the repair of injuries, he shows 
plainly that in all such cases the new structures are 
merely aggregations of elements analogous to con- 
nective tissue, and that the power of producing 
them is in inverse ratio to the amount of power 
consumed in the development and growth of the 
individual, and in its maintenance in the perfect 
state. 

He further says that — 

" In man and other mammalia, a true reproduction after 
loss or injury seems limited to three classes of parts : 1. To 
those which are formed entirely by nutritive repetition, such 
as the blood and epithelia. 2. To those which are of lowest 
organization, and (which seems of more importance) of low- 
est chemical character ; as the gelatinous tissues, the cellu- 
lar and tendinous, and the bones. 3. To those which are 
inserted in other tissues, not as essential to their structure, 
but as accessories, as connecting or incorporating them with 
the other structures of vegetative or animal life ; such as 
nerve-fibres and blood-vessels. 

"With these exceptions, injuries or losses in the human 
body are capable of no more than repair, in its most limited 
sense ; i.e., in the place of what is lost, some lowly organ- 
ized tissue is formed, which fills up the breach, and suffices 
for the maintenance of a less perfect life."* 

* Surgical Pathology, p. 115. (Am. ed., 1854.) 



REPARATIVE PROCESS ACCIDENTAL. 243 

The general law, then, which seems to me to have 
been developed in the foregoing discussion, is that 
the alteration in a tissue which we call inflamma- 
tion consists, in part, of a stimulation to the ele- 
ments of such a tissue, by reason of which they 
proliferate or give rise to new cells. And the cells 
produced under this law may go on to a develop- 
ment in connection with their parent textures, in- 
fluenced entirely by surrounding circumstances, so 
as to incidentally effect such repair as they may. 
Incidentally, altogether; for the process by which 
the two layers of the pleura become bound together 
by organized and living tissue, which in its subse- 
quent completion contracts so as to draw in and 
deform the side of the thorax, is in all its essentials 
the very same with that by which the ravages of a 
burn are repaired, with the frightful disfigurement 
so apt to attend its latter stages. 

Let me here go back for a moment to explain one 
point. In the quotation which I just now made 
from Paget, it was said that the accessories of other 
structures, such as vessels or nerve-fibres, might be 
reproduced; and the inference might perhaps seem 
to be a just one, that if such parts might be repro- 
duced, they might also be generated cle novo. Such 
however is not the case. Cut out a small portion, 
say the one-eighth or the quarter of an inch, of a 
nerve, and the lymph-cells deposited in the gap may 
assume the functions, if not the physical characters, 
of the lost elements; but it is obvious that this is 
quite a different affair from the sprouting of a new 
nerve-filament into a granulation. And so also of 
vessels. 



244 LECTURES ON INFLAMMATION. 

There is one point in connection with, the estab- 
lishment of cicatrices in ulcers, which have healed 
by granulation, which has never been so far as I 
know satisfactorily explained ; it is the way in which 
the very soft, florid, and vascular substance of the 
granulations becomes converted into the firm, pale, 
and apparently non-vascular fibrous tissue of the 
permanent healing medium. But upon the views 
I have stated in regard to the original mode of 
origin of the vessels in such a new structure, it 
seems to me that their disappearance may be ac- 
counted for without difficulty. The new elements 
acquire characters, both gross and microscopical, 
closely allied to those of ordinary connective tis- 
sue; their nutrition no longer goes on so actively 
as before, for proliferation has ceased, and the rapid- 
ity of interchange between the elements and the 
blood is always greater during development than in 
maturity. Hence the supply of blood which in the 
former stage of the construction was no more than 
adequate, would in the latter be altogether exces- 
sive. There is therefore a diminished attraction 
exerted by the new-formed tissues upon the blood 
— the current in the vessels slacks, and the shrink- 
ing of the lymph-corpuscles into fibres tends to 
narrow the channels by which the blood finds its 
way between them. And when the so-called struc- 
tureless character of the capillaries is remembered, 
it can easily be seen that their closure would sim- 
ply rank them with the amorphous intercellular 
substance which exists in so many of the simpler 
tissues. 



INFLUENCE OF DIFFERENCES OF STRUCTURE. 245 

We have now, gentlemen, gone over the whole 
of the natural history of inflammation, inquiring 
into its phenomena and their causes, local and gen- 
eral, its modes of termination, and its incidental 
effects in the formation of lymph and pus. It re- 
mains for us to study the modifications impressed 
upon the disease by the varieties of structure in the 
tissues which form its seat. That such modifica- 
tions exist, is a matter of constant observation in 
medical and surgical practice — and the misappre- 
hension of them has given rise to many mistakes 
in pathology. I think that a careful study of them 
will show that they are non-essential. 

Upon a strictly anatomical view, we find three 
great structural classes, under which the constit- 
uents of the body may be ranged. Mentioned in 
the order of their seeming importance, these are 
(1) the parenchymata, (2) the mucous membranes, 
(3) the serous membranes. 

Under the first of these classes are included brain 
and nerve-tissue, the blood, blood-gland-tissue, mus- 
cle-tissue, and the mechanical structures, — bone, 
cartilage, and connective tissue. This latter item 
is obviously of great importance, embracing as it 
does the outer and middle coats of all the vessels, 
down to the mere capillaries, and the framework in 
which all the special organs are imbedded. 

The mucous membranes comprise the pulmonary, 
alimentary, genito-urinary, mammary, and auditory 
epithelial linings, as well as the skin, which is con- 
tinuous with them all. Moreover, to several of 
these must be added glandular appendages, or fol- 
licular offshoots. 



246 LECTURES ON INFLAMMATION. 

The serous membranes, or shut sacs, include the 
peritoneum, pleura, pericardium, lining membrane 
of the entire vascular and lymphatic system of ves- 
sels, cerebro-spinal arachnoid, tunica vaginalis testis, 
joint-cavities, and bursse. 

Perhaps it would be more strictly correct to make 
only two classes, the parenchymatous and the mem- 
branous or epithelial — the former including all those 
organs whose mass, uniform and persistent in its 
elements, is endowed with a function peculiar and 
special to itself — while the latter comprises those 
which form surfaces — which depend on the accident 
of their situation for their function. Each cell is 
like all the rest, and any one, if it could be wholly 
isolated and yet supplied with nutritive material and 
the other conditions of its life, would either fulfil 
or be capable of fulfilling its function. Such is the 
case with the constituents of bone, cartilage, ten- 
don, both kinds of muscle, connective tissue, all the 
special gland -structures, and all the parts of the 
nervous system. "Whatever the function of these 
elements, it is intrinsic — the mechanical tissues, as 
bone, cartilage, tendon, muscle, and connective tis- 
sue, are resistent or contractile in themselves, and 
not by virtue of any accidental position in which 
they may be found — the gland-cells, of the liver, 
kidney, etc. stand in a special relation to the blood, 
be that relation considered as merely chemical, 
or as a vital and mysterious one. Above all, the 
nervous system, the attribute of the higher organ- 
isms only, more complex and more fully developed 
according to the rank of its possessor in the scale of 
being, and culminating in man as the exponent of 



MUCOUS AND SEROUS MEMBRANES. 247 

the soul, is composed of special tissues, the elements 
of which are indeed mutually dependent, but which 
are as peculiar in structure as in function. 

I know of no reason why to the list above given 
there should not be added the blood-mass, as a 
special organ with a universal relation to the tis- 
sues. It has several functions, like some of the 
other special or parenchymatous tissues — the most 
prominent being the carrying of nutriment and of 
oxygen to the other tissues — and depends like them 
upon a supply from without for its life. 

£Tow when we come to examine the membranous 
systems, we find that while their essential structure 
is the same throughout, a vascular network inter- 
laced with connective tissue, in relation with a sur- 
face coated with epithelium, some of them commu- 
nicate by continuity with the external surface, 
while others are shut sacs — and as this difference 
of arrangement corresponds with some differences 
in both the normal and the abnormal processes 
which take place in these structures, we may make 
the further division into mucous and serous mem- 
branes. 

In the mucous membranes we find the epithelial 
layer thicker than that of the serous, and composed 
of many more strata. It is thrown off continually, 
more or less rapidly in different parts, and mingled 
with the detached epithelium are found, on the in- 
ternal membranes, certain corpuscles known as 
mucus corpuscles. 

Beneath the epithelial layer w^e find a mass of 
connective tissue imbedding the vessels; it is in 
general thicker and softer than that underlying the 
epithelium of the serous membranes. 



248 LECTURES ON INFLAMMATION. 

The mucous membranes embrace, besides the 
skin, the alimento-pulmonary, genito-urinary, and 
auditory. 

In the serous membranes we find a thin, firm, 
persistent layer of epithelium, overlying a com- 
paratively thin subserous stratum of connective tis- 
sue. Their secretion is a clear, viscid liquid, in 
some of them so small in amount in health as to 
be a mere exhalation, in others much more abund- 
ant. The anatomical structure is in the mucous 
membranes in a state of evolution, in the serous in 
a state of involution. 

Now it will be easily seen that the parenchyma- 
tous textures and the mucous membranes are often 
in close relation with one another; as is the case 
for instance with the proper gland-tissue of a sali- 
vary gland and its ducts. The two are more dis- 
tinct in the case of the liver than in that of any 
other gland. 

]STow although the essentials of the process of 
nutrition are exactly the same in all these classes, 
the arrangement of the tissue-elements in each, and 
their relation to the vessels, are peculiar. In the 
first class, which I have called the parenchymatous, 
the cells or fibres as the case may be, are massed 
together, and the vessels of supply are carried 
through those masses so as to form a network. 

It is upon these differences of arrangement, which 
are non-essential, that the differences in nutrition, 
which are also non-essential, depend. And it is but 
a step further to say, that if the nutrition be dis- 
turbed, as in inflammation, we might naturally ex- 
pect to find that the results of such disturbance pre- 



INFLUENCE 0E VARIETY IN TISSUE. 249 

sented even wider and more apparent differences 
than the normal state of things. To take the most 
obvious instance, at the first glance there would 
seem to be a radical distinction between a boil and 
an inflammation of the pericardium. But on a 
closer scrutiny it becomes evident that there is in 
each case redness, heat, swelling, pain, and disorder 
of function. Moreover, there is in each case a for- 
mation of adventitious elements, — of lymph cor- 
puscles and fibrillse. And by pursuing the only 
rational mode of inquiry in natural science, — by fol- 
lowing up the successive shades of difference, we 
establish a chain of gradations between these two 
extremes, and bring them both under the same law 
as regards their normal as well as their abnormal 
conditions. 

The process of inflammation can take place only 
in the substance of tissues, since it is here only that 
there exists a nutrition to be deranged. And hence, 
in the case for example of the skin, or of a mucous 
or serous membrane, the actual seat of the disorder 
must be in the subcutaneous, or submucous, or sub- 
serous layer of connective tissue, in which the nutri- 
tion is carried on. 

But although no objection be made to the state- 
ment that the essence of inflammation is theoreti- 
cally the same in all these cases, and that in fact it 
is seated in analogous structures, the course and 
effects of the disease are in appearance widely dif- 
ferent; and this fact gives color to the idea so gen- 
erally held that there is in mucous membranes, for 
instance, an inherent tendency to form pus or to 
ulcerate, while the serous membranes are in some 

22 



250 LECTURES ON INFLAMMATION. 

mysterious way inclined to throw out lymph, as the 
expression is, and to form adhesions between their 
opposed surfaces. 

If the description given of the phenomena and 
effects of inflammation be recalled, it will be evident 
that they are exhibited most clearly in the paren- 
chymatous tissues, among which may be included 
the proper texture of the skin. In the mucous 
membranes, and especially in the thinner ones, the 
readiness with which disorder of the secretions, 
whether in the way of excess or of changed char- 
acter, takes place, is apt somewhat to mask some 
of the features of the primary disease. On the other 
hand, in the serous membranes or shut sacs, the 
tendency is to the copious pouring out, within the 
cavity, of a liquid possessing such characters as in- 
dicate its inflammatory origin. In both these latter 
cases, the deposition of lymph, although it occurs in 
the submucous or subserous connective tissue, is 
very apt to be overlooked, from its relatively small 
quantity. 

I think, however, that I am safe in saying that if 
you put a mucous membrane into the condition of 
a serous membrane, or the converse, you will in- 
evitably find that they will no longer differ in the 
manner just mentioned. Let us reduce this abstract 
statement to the concrete. 

In the vaginal mucous membrane we have, upon 
a basis of connective tissue, layer upon layer of epi- 
thelial cells. The constant succession of these cells, 
and the accumulation and flowing off' of mucus and 
of the discharges from the uterus, must obviously 
prevent anything like adhesion between the opposed 



MUCOUS AXD SEROUS MEMBRANES. 251 

surfaces in the normal state of affairs. And when 
inflammation occurs, the abundant proliferation of 
the epithelial cells, giving rise to pus or to large quan- 
tities of mucus, will generally have the same effect. 

In the pleura, a perfect serous membrane, the con- 
nective tissue which forms its basis is less abundant, 
and there is only a thin layer of closely attached 
epithelial cells on the surface. When inflammation 
takes place, the formation of lymph readily occurs, 
and the deposit, like the cells generating it, has no 
chance of being thrown off; it is therefore placed 
under circumstances highly favorable to its continu- 
ance, and to its assumption of a permanent connec- 
tion w r ith the surface whence it came. If from the 
6tate of the blood, or from the character of the local 
disturbance, the lymph formed is of poor quality, or 
if the access of air to the cavity of the pleura is 
added to the other causes of irritation, the adventi- 
tious elements may break down into pus, and the 
pleurisy becomes an empyema. 

Now if any portion of the mucous membrane loses 
a great part, or the whole, of its epithelial covering, 
and if, moreover, the discharges cease to flow so as 
to keep the sides of the passage, thus denuded, 
separate, there will ensue as firm a union as would 
be possible between the costal and the pulmonary 
pleurae. For in fact, the special conditions of the 
mucous membrane are done away with, and it comes 
to resemble a serous membrane. 

And conversely, if, as often happens in the case 
of empyema, the deposit of lymph on the pleural 
surface is thick, and tends to break down continually 
into pus, the anatomical peculiarity which distin- 



252 LECTURES ON INFLAMMATION. 

guislies the serous membrane no longer exists, and 
there is no longer the special tendency to the forma- 
tion of adhesions which previously pertained to it. 

I believe, but I have not had an opportunity of 
investigating the point with reference to our present 
inquiry, that sections of inflamed serous and mucous 
membrane would show that, in the one case as well 
as in the other, there was a proliferation of the con- 
nective-tissue cells about the vessels, or in the lan- 
guage usually held, a deposit of lymph, alike in the 
subserous and in the submucous tissue. And as to 
that which is superficial, the circumstances under 
which the newly-formed cells in the mucous mem- 
brane are placed are such as to favor their degenera- 
tive change into pus. 

A sort of neutral ground between these two ex- 
tremes is found in the parenchymatous tissues, such 
as the glandular or muscular, or the connective 
where it exists in quantity. Here an inflammation 
will give rise to the formation of lymph, which may 
become organized into a permanent relation with 
the original structures, just exactly as that which 
constitutes a pleuritic adhesion does, or which may 
break down into pus and be discharged, as that 
would be which had its descent from the epithelial 
cells of a mucous membrane. 

I think, therefore, we may state that in the first 
planning out of the living organism, the simple laws 
of structure and nutrition were laid down ; and that 
when nutrition is disturbed by the excitement of 
inflammation, the course of the disease in any part 
conforms as far as it may, or rather corresponds, to 
the normal order of things. This view seems to me 



NO SPECIAL LAW. 253 

far more rational, and much more in accordance 
with the idea of an all- wise Creator, than the suppo- 
sition that, disease being inevitable, a special pro- 
vision was made by which it should be productive 
of the least possible degree of harm, or its ravages 
repaired. 



22* 



LECTURE X. 

THE THERAPEUTICS OF INFLAMMATION — GENERAL RELATIONS OF PA- 
THOLOGY AND THERAPEUTICS — INFLAMMATION ALWAYS CALLS FOR 
TREATMENT — OBJECT OF THIS, TO RESTORE NORMAL CONDITIONS OF 

NUTRITION VARIOUS WAYS OF ATTAINING THIS OBJECT EFFECTS 

OF COLD OF WARMTH AND MOISTURE OF COUNTER-IRRITANTS OF 

GENERAL BLEEDING — OF DERIVATIVES OF LOW DIET — OF ANO- 
DYNES — OF ASTRINGENTS — OF ALTERATIVES THE ESSENTIAL AIM 

IN ALL THESE CASES THE SAME — CONCLUSION. 

The subject, gentlemen, with which I propose to 
occupy your attention in this, the concluding lecture 
of my course, is that of the therapeutics of inflam- 
mation. It is not, however, my design to give you 
a mere catalogue of the remedies to be employed in 
this disease, and their modes of application, since 
you are probably familiar with all this from other 
sources. What I wish to do is to test the views 
which I have advanced in former lectures, by the 
results of treatment. For we may be sure that 
pathological theories are wrong, which are at vari- 
ance with such results. 

Pathology is and must be subordinate to thera- 
peutics; subordinate as an object, but superior as a 
science. In fact, it would be more correct to say 
that the former is a science, the latter an art based 
upon it. All medical knowledge is useful just so 
far as it enables us to prevent or to cure disease. 
Just so far as disease is a mystery to us, our treat- 
(254) 



PATHOLOGY AND THERAPEUTICS. 255 

ment of it is empirical ; and the more thorough our 
comprehension of its phenomena and their causes, 
the more directly and intelligently can we under- 
take its prevention or its cure. On the other hand, 
a due appreciation of the value and mode of action 
of remedies cannot but throw light upon the condi- 
tions against which they are employed. 

According to the popular idea, a disease is an 
entity, which, as the phrase goes, gets into the sys- 
tem or into a part; and we send in a medicine to 
extract or neutralize it. Thus it is often said, that 
"the inflammation is drawn out" of a part, as for 
example by leeches or by a poultice. It is probable 
that the idea implied in this expression is often un- 
consciously entertained by physicians ; and in regard 
to some diseases, as for instance syphilis, there can 
be no doubt that such a theory not only prevails, 
but would be assigned as the basis of sound and suc- 
cessful modes of practice. Thus it is often asserted 
that iodide of potassium is a specific for syphilis, 
and hence that it neutralizes the poison, whatever 
that may be, which exists in the blood. Here, how- 
ever, we are in the region of avowed empiricism; 
we know from experience that many cases of syphi- 
lis have been benefited by the use of the iodide, and 
are encouraged to administer it to other patients 
similarly affected. But the happy results of the 
practice do not by any means substantiate the 
theory. The history of medicine shows many in- 
stances in which empiricism has been set aside by 
empiricism, as for example when Ambrose Pare 
was compelled to forego the use of boiling oil in 
some cases of gunshot wound, and discovered to his 



256 LECTURES ON INFLAMMATION. 

amazement that the belief in the necessity of such 
applications was without foundation. And the prog- 
ress made through empiricism has sometimes been 
rendered positive and permanent by the advance of 
scientific pathology, as in the ^instance just adduced. 
But there are diseases, such as the malarial fevers, 
which still remain inexplicable, although we treat 
them empirically with success. The fact is that the 
empiricism is only in less degree in one case than 
in another; or at least it seems as if in one the chain 
of causes and effects were shorter and more easily 
traced than in the other. 

Now it may be that many of the remedies in com- 
mon use in the treatment of inflammation are so 
employed upon the ground of experience only; or 
at least that, being proved by experience to be of 
value, the theory of their action is either incorrect 
or inadequate. Let us see whether we can put those 
modes of treatment on a scientific basis, and at the 
same time whether in this attempt we can derive 
any further light upon the points formerly discussed. 

The object of all therapeutics must be, either 
directly or indirectly, to convert the abnormal state 
of things into the normal, as nearly as possible. 
Sometimes chemical agents answer this purpose; as 
when the stomach is irritated by the presence of 
acid matters, and we put an alkali into it to neu- 
tralize the acid. Sometimes mechanical support is 
needed, as when a broken bone no longer serves as 
a stay for the surrounding soft textures. When an 
amputation is in any way rendered necessary, it is 
upon the same principle. The crushed or diseased 
limb is in a state of irreparable abnormity, which 



TREATMENT ALWAYS CALLED FOR. 257 

involves disturbance to the entire organism ; and 
the surgeon simply removes the affected part in 
such away that the stump shall be as quickly and as 
thoroughly healed as possible. The very word ther- 
apeutics, or healing, implies the making whole, or 
healthy, or normal. 

It is sometimes the case that medicine, more fre- 
quently that surgery, aims directly at the removal 
of an offending cause. Sometimes, on the other 
hand, we must direct our efforts to the counteraction 
of its effects. And there are many instances, espe- 
cially in medical practice, in which the chain of 
conditions intermediate between the cause and its 
palpable effects, as well as between the remedy and 
its resulting benefit, is long and intricate. Of this 
latter statement striking illustrations may be found 
in abundance among diseases of the kidneys. 

Now you will remember that one of my earliest 
assertions in regard to inflammation was that it con- 
stituted, always and everywhere, a disease. And 
hence it always calls for treatment. If for any pur- 
pose the surgeon excites it, as a less evil than some 
pre-existing abnormal state, he looks upon it as a 
temporary condition only. We never think of es- 
tablishing an inflamed state of any portion of the 
skin as a permanence in the economy. A blister, a 
seton or an issue may be kept up for a time, but as 
soon as its beneficial effect is fully secured, measures 
are taken to heal it. Often, indeed, the mere re- 
moval of the artificial irritant suffices, and the tissues 
affected by it subside into their natural state. 

And when we consider the relation of inflamma- 
tion to other diseases, we see that our therapeutics 



258 LECTURES ON INFLAMMATION. 

are directed very much by it. In some cases this 
relation is one of cause and effect; the inflammation 
is allayed, and all the symptoms disappear. Or the 
inflamed state of an organ or set of organs depends 
on some other abnormity; and then the primary 
disturbance is the first object of our remedial meas- 
ures, while we either trust to the removal of this 
for the consequent subsidence of the inflammation 
which ensued upon it, or aim at once at the correc- 
tion of the cause and the alleviation of the effect. 
But in every case the essential indication is the 
same, viz.: to restore as far as possible the normal 
condition of things. 

Moreover, the mode of departure from this con- 
dition is, as was argued in the earlier lectures of 
this course, a disturbance of nutrition. So entirely 
is this view sustained in regard to all those inflam- 
mations which can be studied, and so completely 
does it accord with what is known of the whole pro- 
cess of life, that it may be accepted as of general 
application. Obviously, therefore, the object of any 
treatment adopted must be to restore or imitate the 
normal conditions of nutrition. Hence the regular 
supply of suitable nourishment, the proper state of 
the part to be nourished, and an influence of the 
nervous system of the right kind and degree, must 
be provided for. It must not be forgotten that there 
may be too great as well as too small a supply of 
nutritive material, nor that the part may have a 
very great power of attraction for the blood with- 
out its nutrition being therefore rendered more 
active. 

Another point which was urged in connection 



THE NATURAL STATE TO BE RESTORED. 259 

with the subject of normal nutrition and its disturb- 
ances was, that the relation between the tissues and 
the blood is one of the utmost accuracy. Every in- 
dividual cell must itself be in connection with the 
due supply of nourishment, and although our deal- 
ings are with masses of cells, yet each one of these 
is concerned in the general result. As a conse- 
quence, in any derangement of nutrition the cells 
composing the affected part must be involved singly 
as well as collectively; and any curative measures 
must in like manner influence each as well as all. 

Furthermore, as in departing from the healthy 
state the tissue-elements, like any other collections 
of material atoms, blindly obeyed the forces brought 
to bear upon them, so in returning to it they are 
wholly passive. They have no tendency to resume 
their normal status. Being subjected to causes of 
derangement, the sum of their combinations is ab- 
normal — those causes ceasing to act, or being over- 
balanced by opposing forces, the tissue-elements are 
again placed under favorable conditions, and obey 
them. 

It is therefore evident, not only that the aim of 
all therapeutical procedures in cases of inflamma- 
tion must be to restore or imitate the natural con- 
dition of things, but that this object may be sought 
in one or more of several ways. First, we may 
endeavor either to remove the irritating cause, or 
to counteract it by sedative agents. Secondly, w r e 
may seek to allay the irritation which exists in any 
mass of cells as the effect of some previous dis- 
turbance. Thirdly, we may seek to restore the 
supply of nutriment to its normal quantity or qual- 



260 LECTURES ON INFLAMMATION. 

ity. Fourthly, we may employ means calculated to 
correct any existing derangement of innervation. 

Now, as will be presently shown, all the tried 
and approved plans for the treatment of inflamma- 
tion are such as answer one or more of the objects 
just enumerated; most of them depend for their 
efficiency upon several influences which they exert 
upon the affected parts. And the more completely, 
in any case, the normal conditions of nutrition are 
either imitated or restored, the more ready and 
thorough will be the return of the part to the state 
of health or freedom from inflammation. The real 
question which presents itself to the physician or 
surgeon in determining upon the course to be 
adopted in any case, is therefore how best to effect 
such an imitation or restoration of the normal state 
of things. 

Of late years, as many of you well know, there 
has been a tendency to the substitution of very sim- 
ple dressings for the complicated formula which 
were previously in vogue. Cold water has been 
found one of the most efficient of local applica- 
tions. Under this term may be included also ice, 
which is the same thing as water at 32° Fahrenheit, 
since it acts by melting, and so assuming this state. 

The fact is well known, that cold is a depressing 
agent. It is a sedative — diminishing innervation, 
and acting also directly upon the tissue-elements of 
any part exposed to it. On analyzing this influence 
a little further, we shall find, I think, that the mod- 
ern doctrine of the correlation of forces has a direct 
bearing upon its explanation. Thus nerve-force, 
heat, and what for want of a better term I have 



EFFECTS OF COLD. 261 

called vital force, are mutually convertible. If we 
lower the temperature of a part, just as when we 
chill a mass of inorganic matter, we do what in the 
language of a few years since would be called ab- 
stracting heat from it; but what according to the 
most recent developments of science is merely 
causing a change in the relation of its atoms. In 
other words, we convert chemical or mechanical 
force, or life-action, or electricity, into heat — and 
as the cold dressing is heated at the expense of the 
affected part, the latter loses a force amounting to 
whatever is necessary for this heating. 

Tracing the chain of phenomena the other way, 
we have, as was stated in our discussion of the 
natural history of inflammation, a rise of temper- 
ature, an irritation of the nervous filaments of the 
part, an increased but deranged innervation, an 
augmented attractive force exerted by the tissue- 
elements upon the blood, and in almost every case, 
— according to some pathologists invariably, — a for- 
mative irritation, resulting in the production of the 
new organisms known as lymph-cells. Here then, 
according to the principles advanced in explanation 
of these symptoms, there is a development of chem- 
ical force, of electricity or of something closely allied 
to it, and of vital force. 2^ot that either of these 
arises de novo, but that the force, whatever it is, 
which constitutes the disturbing cause as such, is 
converted into these forms. 

Xow when a cold dressing is applied, the conduc- 
tion of heat which at once begins, and by which the 
temperature of that dressing is raised, is owing to 
the conversion of the forces above named into heat. 

23 



262 LECTURES ON INFLAMMATION. 

The chemical, electrical, and vital forces whose ex- 
altation in the affected part constituted the inflam- 
matory condition, are changed into the heat neces- 
sary for the bringing up of the temperature of the 
dressing. It would be out of place for me here, 
even if it were in my power, to examine into the 
nature of heat and the laws of its transmission. 
The terms which I have used are not yet abandoned, 
although it may be that others more strictly in ac- 
cordance with the theories of modern philosophy 
may before long be substituted for them. 

The principle which I have before had occasion 
to urge, that for every effect there must be an 
adequate cause, and that for every force there must 
be an equivalent effect produced, comes in here 
again. It is no more conceivable that in any case 
of inflammation there should be a greater amount 
of heat developed than is exactly equal to the forces 
expended in producing it, than that under any cir- 
cumstances two and two should make live. .Nor is 
it possible that the application of cold should destroy 
any of the forces operating in the tissues which are 
inflamed. Force and matter are alike convertible, 
and alike indestructible. 

From all that has now been said, we may derive 
the following statement: In any living organized 
part, there are certain changes continually affecting 
the particles composing it, by reason of the mechan- 
ical, chemical, and vital forces of which those par- 
ticles are the agents; if any force acting from with- 
out disturbs the mass, it produces an irritation 
exactly equivalent to itself, becoming converted 
into vital, chemical or mechanical forces; and by 



EFFECTS OF COLD. 263 

the application of suitable means these m&y be 
again converted into heat, which is further con- 
ducted away from the part, to produce an effect 
exactly equivalent to itself upon matter which does 
not belong within the organism. 

The application of mere cold to an inflamed part, 
therefore, affords relief in several ways. It is a 
sedative because it induces a conversion of electri- 
cal and vital force, admitting that this latter exists, 
into heat; it absorbs the force which would consti- 
tute an attraction between the tissues and the blood/ 
and that which w r ould bring together the different 
atoms by chemical affinity into combustion, chang- 
ing them also into heat. And just as the prime 
cause of the disease is adequate to its production 
in a certain degree and extent only, so the remedy 
applied can give rise to no more than its legitimate 
effect. 

Now in regard to the effects of cold, as also in 
regard to those of anv other remedial a^ent for the 
disease in question, it must be remembered that 
there are certain other modes in w T hich it may in- 
fluence the part as well as by this mere abstraction, 
if the phrase may still be used, of heat. For in- 
stance, it is a matter of common observation that 
the involuntary or at least the non-striated muscular 
fibres contract under its impression, and that as a 
general law matter diminishes in bulk as its temper- 
ature is lowered. And in this way also the impaired 
conditions of nutrition are rendered more nearly 
normal. ^ Thus if the skin be involved, the applica- 
tion of cold will lessen the calibre of the smaller 
arteries, not only by causing their circular fibres to 



264 LECTURES ON INFLAMMATION. 

shorten, but also by the organic muscular fibres of 
the part being drawn up, so as to compress the 
channels through which the excessive supply of 
blood finds its way to the seat of the disturb- 
ance. 

It can scarcely be needful for me to argue that all 
the modes in which cold has hitherto been shown 
to act in reducing inflammation involve also the 
favoring of a return of the tissue-elements to their 
normal state. But if this be the case, then the 
% elfect of the remedy may be summed up as a re- 
storation of the essentials of nutrition, viz.: of a 
right state of the parts to be nourished, a due sup- 
ply of suitable nutriment, and a healthy innerva- 
tion. So far, therefore, the idea is borne out that 
inflammation consists in a disorder of nutrition. 

Another plan of treatment in this disease, which 
often proves of great benefit, is that by warmth and 
moisture. It makes very little difference whether 
the simple warm-water dressing, or poultices, be 
chosen, since both act on the same principle. Here 
the most prominent result is the inducing of free 
secretion, and the placing of the inflamed part in 
circumstances analogous to those of its healthy 
state. The relaxation of tissue which is brought 
about by a combination of warmth and moisture, 
and the soothing of irritated nerve-filaments as well 
as of the irritated cells, together with the absorp- 
tion of water which probably often takes place, are 
the main, or at least the most apparent, advantages 
/ thus gained. 

Every one knows how much less the irritation is, 
and how much more readily healing takes place, 



BLISTERS AND EMOLLIENT DRESSINGS. 265 

after subcutaneous operations than when the air is 
admitted. And in almost all superficial inflamma- 
tions it may be assumed that the protection afforded 
from the air, by a bland and non-stimulant dressing, 
which approaches somewhat in character in this re- 
spect to that of a mass of living tissue, must be of 
no small consequence as favoring the return of the 
affected part to its natural and healthy state. In 
deeper-seated inflammations, the advantage derived 
•from poultices or warm-water dressings is probably 
attributable to the reflex influence upon the nervous 
system of the parts involved. 

And here let me digress for a moment, and anti- 
cipate what I shall have to say in regard to counter- 
irritants. Sometimes, as iu pneumonia or pleurisy, 
we apply a blister to the skin covering the affected 
part, with good results. Sometimes, on the other 
hand, we employ a poultice, and find it of advant- 
age. And it may seem as if there were an incon- 
sistency in thus seeking the same end in ways so 
opposite. But in the one case the irritation of the 
skin, by exciting the cutaneous nerves, relieves 
those of the deeper textures; according to the law 
mentioned in an earlier lecture, by virtue of which 
there is a balance maintained between one part and 
another. The stimulation of the skin is very pow- 
erful, and outweighs the less severe but more dan- 
gerous disorder of the deeply-seated part. 

In the other case, under the law of reflex action 
the visceral nerves, and therefore the tissue-elements 
supplied by them, are soothed by the impression on 
the cutaneous nerves — while, especially when the 

23* 



266 LECTURES ON INFLAMMATION. 

intervening structures are of no great thickness, the 
relaxing effects of the warmth and moisture are 
directly felt by the parts which are inflamed. 

Some counter-irritants, as I need perhaps hardly 
remind you, have the effect also of abstracting blood 
from the vessels of the part. Cups, leeches, and 
scarifications are in various degrees useful in this 
way. It is obvious that the lessening of the amount 
of blood supplied to the excited tissues must deprive 
them of the excess of pabulum which they are at- 
tracting to themselves, and by cutting off their un- 
duly abundant supplies must bring them into closer 
conformity with the standard of health. Here then 
is an actual loss from the sum total of the blood-mass, 
and therefore the benefit is permanent. 

General bleeding, once so universally practised 
in the treatment of inflammation, acted in the same 
way. The blood-mass, being in relation with all 
the tissues, cannot be reduced in quantity without 
the effect being first felt at any point where it is in 
excess, — in congested or inflamed parts. It was 
however not only as the direct consequence of the 
taking away of so much blood, but also by the 
diminution of the heart's action from the less vol- 
ume of the mass to be propelled, and from the 
sedation of the nervous system, which when in 
greater degree would constitute syncope, that the 
circulation within the affected part was lowered, 
and the excess of nutritive or formative irritation 
by so much reduced. Moreover, the same depres- 
sion of the nervous system which would thus lower 
the action of the heart, would also diminish the in- 
nervation of the inflamed part, and thus by affecting 



DERIVATIVES. 267 

another of the conditions of nutrition would render 
it more nearly normal. 

The whole class of derivatives, — diaphoretics, 
diuretics, purgatives, owe their value simply to the 
fact that they give another direction to the blood- 
current and to the nerve-force. They thus act upon 
three of the essential elements of nutrition, the 
quantity of the pabulum, its quality, and the in- 
nervation which we know is necessary to the pro- 
cess, and which is increased or deranged, or both, 
in inflammation. Often the relief given in these 
respects goes very far to put an end to the disease, 
since the tissue-elements themselves return to their 
normal state. Another source of the efficacy of 
such remedies is that they allay the constitutional 
fever, and as this, which at first is lighted up by 
the local disturbance, reacts upon and aggravates 
the latter, its subsidence removes one prop from the 
disease. In regard to all these processes, it seems 
to me that the modern doctrine before alluded to of 
the correlation of forces has a most important bear- 
ing. If the nerve-force be converted into the chem- 
ical, electrical, or vital force which is required for 
secretion, or under which that change of relation 
between the atoms, which constitutes secretion, 
takes place, then that nerve-force is no longer avail- 
able as an element of formative irritation in the 
diseased part, or as an element of the systemic dis- 
turbance known as fever. If the blood is used for 
the purpose of secretion on the cutaneous surface, 
or on that of the urinary or alimentary mucous 
membrane, it cannot be also used by the irritated 
part in carrying on the morbidly increased and 



268 LECTURES ON INFLAMMATION. 

deranged nutrition which enters so largely into the 
process of inflammation. 

The influence of low diet in reducing inflamma- 
tion is obviously analogous to that of the other 
depletory measures already spoken of. It not only 
deprives the irritated part of the pabulum for its 
excessive nutrition, but it cuts off a source of ex- 
citement from the nervous system, and thus dimin- 
ishes innervation. 

Anodynes, when applied directly to the tissue or 
organ which is the seat of the disease, act mainly 
upon the nerves distributed to it, and perhaps also 
upon the tissue-elements themselves. Their local 
employment is accordingly most beneficial when 
the part concerned is one of great sensitiveness, so 
that pain is a prominent symptom of the disorder. 
"When they are so given as to be absorbed into the 
circulating blood, and to act on the central nervous 
system, they prevent in a measure that reflex action 
which was mentioned as an important element in 
the chain of morbid phenomena. And as you well 
know, when they are so used it is generally in com- 
bination with such remedies as promote secretion — 
so that we have not only the soothing effect belong- 
ing to them, but also the derivative effect upon the 
blood -mass and the nerve -force, which has been 
already discussed. 

Astringents are very valuable as local applica- 
tions in inflammation. They act not only upon the 
blood-vessels, shrinking them and causing a dimi- 
nution in the quantity of blood which passes through 
the irritated part, but also upon the cells. Some of 
them, as for instance the acetate of lead, seem to 



ASTRINGENTS. 2G9 

possess a certain degree of sedative power over the 
nerves, and perhaps over the tissue-elements also. 
I do not know that any satisfactory explanation of 
this power has ever been given, but the fact can 
hardly be questioned. Mechanical pressure, espe- 
cially in parts endowed with no great sensibility, 
has much the same effect. 

Certain articles in our materia medica have long 
been recognized as valuable local remedies in in- 
flammation, without the mode of their action being 
clearly understood. Among these one of the most 
prominent is the nitrate of silver. This salt is a 
powerful astringent, and has also a marked effect in 
deadening the sensibility of parts to which it is ap- 
plied. Tannic acid, and some of the salts of iron, 
have like properties. Iodine acts in the same way. 
It may be that the astringency of all these articles is 
the sole source of their efficacy, being exerted upon 
the nerve-tilaments with which they come in con- 
tact. It certainly does not seem philosophical to 
ascribe to them any special and mysterious agency, 
without stronger proofs than have yet been adduced. 

Astringents and anodynes may be combined with 
great advantage in the treatment of inflammations; 
as for instance, in cases of ophthalmia, where we have 
to deal with a superficial tissue, very vascular and 
very sensitive. Here we may employ the sulphate 
of zinc as an astringent, to cause shrinking of the 
blood-vessels, and we may add the sulphate of mor- 
phia as an anodyne, to allay pain. 

There is one class of remedies for inflammation, 
whose efficiency has been long known, but whose 
exact mode of operation is still undiscovered. I 



270 LECTURES ON INFLAMMATION. 

allude to what are called alteratives. Mercury in 
its various forms may be taken as the type of this 
class, which includes also iodine, arsenic, and ap- 
parently some of the salts of potassa. It is a sin- 
gular circumstance that the salts of iodine and 
arsenic which have been most extensively and suc- 
cessfully employed as alteratives are those with 
potassa. The iodide of potassium, called by some 
chemists hydriodate of potassa, and the arsenite of 
potassa, are well-known agents of this class, and 
probably the soluble salts of this alkali, such as the 
nitrate, induce scurvy by an excess of like influence. 

It is generally supposed that these substances 
enter into combination with the blood, and in some 
way influence its chemical composition, so as to 
render it less nutritive; according to the older in- 
vestigators, they lessened its fibrine-forming power. 
But the subject is so far from being in any degree 
thoroughly understood, and indeed involves so many 
intricate questions in physiology, that time would 
fail me, even if I felt equal to the task of discuss- 
ing it. 

These articles differ somewhat in their methods 
of employment. Mercury and arsenic produce their 
effects most completely when they are insinuated, 
as it were, little by little, into the circulating blood. 
The former has a definite direction toward certain 
organs, of which the liver is the chief. Their solu- 
ble salts are powerfully irritant; arsenic itself is 
never given medicinally, while as you know mer- 
cury often is. 

Iodide of potassium is capable of being taken into 
the stomach, and absorbed, in very much larger 



ALTERATIVES. 271 

quantity than either of the articles above mentioned. 
Its general distribution in this way is more effective 
than its local application — and its power is greatly 
increased, according to Parker and other writers on 
syphilis, by the addition to it of minute quantities 
of the more energetic salts of mercury. 

As to the local employment of these remedies, 
they are of most value in discussing swellings, such 
as glandular enlargements, and the indurated masses 
of lymph which often remain after the inflammation 
has subsided which gave rise to them. 

Xow in all these cases, obscure as the precise 
mode of action of the remedies may be, the general 
fact is sufficiently obvious, that they exert an influ- 
ence upon nutrition. Whether they act upon the 
blood alone, simply changing its composition, or 
have besides this an effect upon the tissue-elements, 
which seems very probable, they influence at least 
one of the factors in the nutritive process, — the 
quality of the nourishment supplied. If they act 
also upon the irritated cells, either, as may perhaps 
be not unlikely in the case of mercury at least, by a 
directly sedative impression, or by combining chemi- 
cally with the cell-contents, it is easy to see how 
powerful their influence must be in modifying the 
nutrition of the part. 

I do not know that there is any evidence to show 
that the alteratives, when locally applied, can influ- 
ence either the quantity of the blood flowing through 
the vessels at the seat of disease, or the innervation 
of the affected tissues. But when they are used as 
general remedies, they may act in both these ways, 
since they would tend to excite secretion, and thus 



272 LECTURES ON INFLAMMATION. 

not only to divert the current of the blood, but also 
to give a different direction to the nerve-force. And 
here it may be proper for me to remark somewhat 
more particularly upon this relation between secre- 
tion and inflammation. When, for example, the 
liver is inflamed, its secretion is checked; and it 
must be borne in mind that the secretion is thus 
checked because the hepatic tissue proper is engaged 
in responding to the stimulus, whatever that may 
be, which excited the inflammation. Now the ad- 
ministration of a mercurial, bringing on free secre- 
tion, unloads the vessels, as the phrase is; or in 
other words, it changes the character of the chemical 
processes which are taking place in the part, so that 
the liver cells perform their function, and use up 
the blood and the nerve-force which are in excess. 

And from this illustration I may proceed to a 
suggestion, which I am not inclined to make too posi- 
tive, but which will perhaps become established by 
further researches. Wherever the process of inflam- 
mation occurs, there is present either connective tis- 
sue or some representative of it. Connective tissue, 
as you know, is distributed everywhere through the 
body, so as to form a sort of soft skeleton, supple- 
mentary to the bony one. As Virchow aptly re- 
marks, "we are almost warranted in regarding this 
tissue as a sort of neutral ground upon which other 
parts may meet, — a special arrangement for their in- 
timate connection; an arrangement which, although 
it exercises no great influence upon the higher func- 
tions of the animal, is still of great importance in 
the matter of its nutrition.' ' 

The idea, then, which I would hint at, is that the 



ALTERATIVES. 273 

theatre of inflammation may perhaps be the connec- 
tive tissue only; the. special tissues being indeed in- 
volved, but in a secondary and merely incidental 
way. Upon this view it may easily be seen how 
the establishment of secretion should relieve inflam- 
mation — since even in the case of the liver the ap- 
paratus of secretion and that of nutrition, using the 
latter term in the strictest sense, would be separate. 
To state the case somewhat differently, the liver- 
cells are imbedded in connective tissue, within 
which ramify vessels and nerves; they are super- 
added to this scaffolding, as it were, upon which 
might have been just as well arranged an apparatus 
for the formation of saliva or urine. The liver-cells 
take what they want for their own nutrition and for 
the fulfilment of their function. When inflamma- 
tion occurs, which we have regarded as a derange- 
ment of nutrition, the secretory process, which de- 
pends upon the secondary nutrition of the liver-cells, 
is interfered with. If re-established, it diverts the 
excess of nourishment and of nerve-force which was 
taken up in carrying on the inflammation, and thus 
relieves the disorder. 

In the foregoing discussion, it has been my en- 
deavor to adhere as closely as possible to a simple 
construction of the facts presented, without warping 
them for the support of any special views or theories. 
I think, however, that they bear out the statements 
previously advanced in regard to the process of in- 
flammation. Those statements, you will remember, 
were that this process is always a disease, and that 
it always consists in a disorder of nutrition — that 

24 



274 LECTURES ON INFLAMMATION. 

the essence of this derangement is a change in the 
mutual relations of the blood and the tissues. It 
was also urged that this change depended, not upon 
an increased or diminished action, a contracted or 
relaxed state of the vessels, nor upon the mere aug- 
mentation of the quantity of blood furnished to the 
part — but that, as the tissue-elements themselves, 
according to the circumstances under which they 
were placed, demanded more or less blood, so their 
state was the immediate cause of all variations in 
this respect. 

There is one point which remains to be noticed. 
I took the ground, not only that inflammation was 
always a disease, but that it was always essentially 
the same — any apparent differences between dif- 
ferent cases depending upon incidental conditions. 
Thus the inflammation in a boil, that around a small- 
pox pustule, and that in a urethra affected with gon- 
orrhoea, are according to this view of like character. 
And so also of that which occurs in diseases usually 
accepted as specific, such as syphilis or erysipelas. 
In any of these cases, so far as local treatment is 
concerned, it is now known that the simplest meas- 
ures are the best. We may indeed seek to correct 
those properties of contagion which are in some 
way attached to the products of these diseases, or to 
counteract the constitutional states in which the 
local trouble either originates or finds a source of 
incessant renewal, but the inflammation itself is 
destitute of specific character, and is shown to be so 
by the simplicity of the remedies to which it yields. 

It may be that such a statement will seem strange 



NO SPECIFIC REMEDIES. 275 

to those who have been accustomed to employ, in 
syphilis or erysipelas for example, certain local dress- 
ings which have in their experience been found to 
answer well, and to which they have therefore been 
led to attach special virtues. But I do not know of 
any such articles, which can be proved to have a 
specific action. I believe they all depend upon the 
astringent, anodyne, and other powers, which have 
been already discussed as belonging to the means 
used in inflammations to which no specific character 
can in any way be ascribed. Eor do I think that 
it can be asserted that there is any one local treat- 
ment which will answer in every case of syphilis, of 
gonorrhoea, or of erysipelas. 

You will perhaps remember, gentlemen, that in 
a former lecture I spoke of the disfavor into which 
many theories have fallen, which were not only pro- 
posed with confidence and defended with energy, 
but which were long accepted as settled principles 
in pathology. Such may possibly be the fate of the 
modern doctrines, rational and sound as we think 
them. But this, so far from discouraging scientific 
research, should stimulate it; leading us not to 
abandon the field, but to increase the honesty as 
well as the caution with which we work out and 
announce our results. 

The views which it has been my duty and my 
pleasure to lay before you, are such as have seemed 
to me to be supported by facts; if their basis is 
sound and adequate, they will stand, — if otherwise, 
they must inevitably fall. And in so saying, I would 
not imply that they are not with me matters of 



276 LECTURES ON INFLAMMATION. 

earnest conviction, or that they are put forth with 
indifference. They are offered as contributions to 
the modern system of pathology, with which I be- 
lieve them to be in accordance. And with it, they 
must stand the test of time and further research; a 
test as severe as infallible. 



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